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2022 PHP (HMO C-SNP) in Miami-Dade, Florida

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the PHP (HMO C-SNP) (H3132 - 001) in Miami-Dade, Florida .

This plan is administered by AHF MCO OF FLORIDA, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the PHP (HMO C-SNP) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings
The PHP (HMO C-SNP) (H3132 - 001) currently has 1,436 members. There are 467 members enrolled in this plan in Miami-Dade, Florida.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4.5 stars. The detail CMS plan carrier ratings are as follows:
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $480 deductible. However, formulary drugs on Tier 5 are excluded from the $480 deductible and have first dollar coverage (or a $0 deductible). So, you are 100% responsible for the first $480 in medication costs for drugs not on the excluded tiers. After you have met the deductible, the PHP (HMO C-SNP) will share the costs of your medications with you -- see cost-sharing below. $480 is the maximum deductible for 2022. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the PHP (HMO C-SNP) formulary (or drug list). There are 3133 drugs on the PHP (HMO C-SNP) formulary. Click here to browse the PHP (HMO C-SNP) Formulary.
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $480, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The PHP (HMO C-SNP)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Generic) contains 1,826 drugs and has a co-insurance of 15% of the drug cost.
  • Tier 2 (Preferred Brand) contains 343 drugs and has a co-insurance of 15% of the drug cost.
  • Tier 3 (Non-Preferred Brand) contains 148 drugs and has a co-insurance of 25% of the drug cost.
  • Tier 4 (Specialty Tier) contains 727 drugs and has a co-insurance of 25% of the drug cost.
  • Tier 5 (Select Care Drugs) contains 133 drugs and has a co-insurance of 0% of the drug cost.
Click here to browse the PHP (HMO C-SNP) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (PHP (HMO C-SNP)) offers Coverage for Few Generics during the Coverage Gap phase. This means that a few (less than 10%) of the generic drugs on the plans formulary (or drug list) and no brand-name drugs will be covered through the coverage gap (or donut hole).

The PHP (HMO C-SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Base Plan **
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $480.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $5
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes
Doctor visits
• Primary: $0 copay
• Specialist: $0 copay (referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization and referral required)
• Lab services: $0 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $0 copay (authorization and referral required)
• Outpatient x-rays: $0 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $75 copay per visit (always covered)
• Urgent care: $0 copay
Inpatient hospital coverage
• $100 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization and referral required)
Outpatient hospital coverage
• $100 copay per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$100 per day for days 21 through 100 (authorization and referral required)
Preventive care
• $0 copay
Ground ambulance
• $150 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $100 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist: $0 copay
• Outpatient individual therapy visit with a psychiatrist: $0 copay
• Outpatient group therapy visit: $0 copay
• Outpatient individual therapy visit: $0 copay
Opioid treatment program services
• In-network: 0% coinsurance or $0 copay (referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay (authorization required)
• Prosthetics (e.g., braces, artificial limbs): $0 copay (authorization required)
• Diabetes supplies: $0 copay (authorization required)
• 0% coinsurance or $0 copay (authorization and referral required)
• Hearing exam: $0 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply, authorization and referral required)
Preventive dental
• Oral exam: $0 copay
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: $0 copay (limits apply)
• Diagnostic services: $0 copay (limits apply)
• Restorative services: $0 copay (limits apply)
• Endodontics: $0 copay (limits apply)
• Periodontics: $0 copay (limits apply)
• Extractions: $0 copay (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply)
• 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: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• 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: Some coverage
• WorldWide emergency: Not covered
• Fitness Benefit: Some coverage
• In-Home Support Services: Some coverage
• 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: Some coverage
• 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
Wellness programs (e.g., fitness, nursing hotline)
• Covered
• $0 copay (authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0 copay (authorization and referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: $0 copay (authorization required)
• Other Part B drugs: $0 copay (authorization required)

Medicare Supplements
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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.