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2020 Medicare Advantage Plan Benefit Details for the Vantage PREMIUM (HMO-POS) - H5576-018-2


2020 Medicare Advantage Plan Details
Medicare Plan Name:Vantage PREMIUM (HMO-POS)
Location:Orleans, Louisiana 70130
Plan ID:H5576 - 018 - 2     Click to see other plans
Member Services:1-866-704-0109 TTY users 1-866-524-5144
— 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 Vantage PREMIUM (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$179.00 (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):$3,000
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:4,002 drugsBrowse the Vantage PREMIUM (HMO-POS) 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:
$4.00$12.00$47.00$100.0033%
Number of Drugs per
  Tier:
4991995457477574
Plan's Pharmacy Search:http://www.VantageMedicare.com
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 610602   PCN: NVTD   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Orleans, Louisiana:less than 10 members
Number of Members enrolled in this plan in Louisiana:998 members
Number of Members enrolled in this plan in (H5576 - 018):1,123 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 5 out of 5 Stars.
Drug Cost Accuracy Rating: 4 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
$179.00$96.50$82.50$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:$50.30$58.30$66.40$74.40
Total Monthly Premium with LIS (Parts C & D):$146.80$154.80$162.90$170.90
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $179.00
• Health plan premium: $96.50
• Drug plan premium: $82.50
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $500 Out-of-network
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,000 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 In-network: $10 copay or 0-20% coinsurance per visit
• Primary Out-of-network: 50% coinsurance per visit
• Specialist In-network: $40 copay or 0-20% coinsurance per visit (authorization required)
• Specialist Out-of-network: 50% coinsurance per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $150 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 50% coinsurance (authorization required)
• Lab services In-network: $0 copay (authorization required)
• Lab services Out-of-network: 50% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $150 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 50% coinsurance (authorization required)
• Outpatient x-rays In-network: $150 copay (authorization required)
• Outpatient x-rays Out-of-network: 50% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $65 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $250 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization required)
• Out-of-network: 50% per stay (authorization required)
Outpatient hospital coverage
• In-network: $150 copay per visit (authorization required)
• Out-of-network: 50% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100 (authorization required)
• Out-of-network: 50% per stay (authorization required)
Preventive care
• In-network: $0 copay (authorization required)
• Out-of-network: 50% coinsurance (authorization required)
Ground ambulance
• In-network: $250 copay
• Out-of-network: 50% coinsurance
Rehabilitation services
• Occupational therapy visit In-network: $10 copay (authorization required)
• Occupational therapy visit Out-of-network: 50% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit In-network: $10 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: 50% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $440 per day for days 1 through 4
$0 per day for days 5 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 50% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $10 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required)
• Outpatient individual therapy visit with a psychiatrist In-network: $10 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required)
• Outpatient group therapy visit In-network: $10 copay (authorization required)
• Outpatient group therapy visit Out-of-network: 50% coinsurance (authorization required)
• Outpatient individual therapy visit In-network: $10 copay (authorization required)
• Outpatient individual therapy visit Out-of-network: 50% coinsurance (authorization required)
Opioid treatment program services
• In-network: 0%-20% coinsurance or $10.00-$40.00 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 50% coinsurance per item (authorization required)
• Diabetes supplies In-network: 0-20% coinsurance per item (authorization required)
• Diabetes supplies Out-of-network: 50% coinsurance per item (authorization required)
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam In-network: 20% coinsurance (authorization required)
• Hearing exam Out-of-network: 50% coinsurance (authorization required)
• 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 In-network: $0 copay (limits apply)
• Oral exam Out-of-network: $0 copay (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services In-network: $0 copay (limits apply, authorization required)
• Diagnostic services Out-of-network: $0 copay (limits apply, authorization required)
• Restorative services In-network: $0 copay (limits apply, authorization required)
• Restorative services Out-of-network: $0 copay (limits apply, authorization required)
• Endodontics In-network: $0 copay (limits apply, authorization required)
• Endodontics Out-of-network: $0 copay (limits apply, authorization required)
• Periodontics In-network: $0 copay (limits apply, authorization required)
• Periodontics Out-of-network: $0 copay (limits apply, authorization required)
• Extractions In-network: $0 copay (limits apply, authorization required)
• Extractions Out-of-network: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: $0 copay (limits apply, authorization required)
Vision
• Routine eye exam In-network: $0 copay (limits apply, authorization required)
• Routine eye exam Out-of-network: 50% coinsurance (limits apply, authorization required)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• In-network: $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment In-network: $40 copay (authorization required)
• Foot exams and treatment Out-of-network: 50% coinsurance (authorization required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 50% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 50% 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: Not covered
• Annual physical exams: Not covered
• Telehealth: Not covered
• WorldWide emergency coverage: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• 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: Some coverage
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered


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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.