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2021 Medicare Advantage Plan Benefit Details for the SummaCare Medicare Sapphire (HMO-POS)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2021 Medicare Advantage Plan Details
Medicare Plan Name:SummaCare Medicare Sapphire (HMO-POS)
Location:Stark, Ohio     Click to see other locations
Plan ID:H3660 - 029 - 0     Click to see other plans
Member Services:1-330-996-8885 TTY users 1-800-750-0750
— 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
Email a copy of the SummaCare Medicare Sapphire (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$76.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,600
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,606 drugsBrowse the SummaCare Medicare Sapphire (HMO-POS) 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$8.00$44.00$100.0033%
• Number of Drugs per
  Tier:		3541899296175833
Plan's Pharmacy Search:http://www.summacare.com/medicare
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Stark, Ohio:522 members
Number of Members enrolled in this plan in (H3660 - 029):4,565 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
• Customer Service Rating: 4 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
$76.00$25.10$50.90$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:$21.10$28.50$36.00$43.40
Total Monthly Premium with LIS (Parts C & D):$46.20$53.60$61.10$68.50
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $76.00
• Health plan premium: $25.10
• Drug plan premium: $50.90
• 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: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,600 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes, contact plan for further details
Doctor visits
• Primary In-network: $0 copay
• Primary Out-of-network: $20 copay per visit
• Specialist In-network: $35 copay per visit (authorization required)
• Specialist Out-of-network: $55 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $0-99 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization required)
• Lab services In-network: $0-6 copay (authorization required)
• Lab services Out-of-network: 30% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $150 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required)
• Outpatient x-rays In-network: $0-99 copay (authorization required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $225 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required)
• Out-of-network: 25% per day for days 1 through 90 (authorization required)
Outpatient hospital coverage
• In-network: $250 copay per visit (authorization required)
• Out-of-network: 20% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20
$180 per day for days 21 through 100 (authorization required)
• Out-of-network: $180 per day for days 1 through 100 (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: $20 copay
Ground ambulance
• In-network: $200 copay
• Out-of-network: $200 copay
Rehabilitation services
• Occupational therapy visit In-network: $35 copay
• Occupational therapy visit Out-of-network: $55 copay
• Physical therapy and speech and language therapy visit In-network: $35 copay
• Physical therapy and speech and language therapy visit Out-of-network: $55 copay
Mental health services
• Inpatient hospital - psychiatric In-network: $225 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 25% per day for days 1 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $35 copay
• Outpatient group therapy visit with a psychiatrist Out-of-network: $55 copay
• Outpatient individual therapy visit with a psychiatrist In-network: $35 copay
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $55 copay
• Outpatient group therapy visit In-network: $35 copay
• Outpatient group therapy visit Out-of-network: $55 copay
• Outpatient individual therapy visit In-network: $35 copay
• Outpatient individual therapy visit Out-of-network: $55 copay
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: 30% 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: 30% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay
• Diabetes supplies Out-of-network: 30% coinsurance per item
Hearing
• Hearing exam In-network: $0-15 copay
• Hearing exam Out-of-network: $55 copay
• Fitting/evaluation In-network: $0 copay
• Fitting/evaluation Out-of-network: $55 copay
• Hearing aids In-network: $795 copay (limits apply)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services In-network: $0 copay
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $55 copay (limits apply)
• 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 In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $0 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered (referral required)
Transportation
• In-network: $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment In-network: $35 copay
• Foot exams and treatment Out-of-network: $55 copay
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required)
Package #1
• Monthly Premium: $28.00
• Deductible:




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