2023 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Devoted PRIME San Antonio (HMO) | ||||
Location: | Guadalupe, Texas Click to see other locations | ||||
Plan ID: | H7993 - 004 - 0 Click to see other plans | ||||
Member Services: | 1-800-338-6833 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 Devoted PRIME San Antonio (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $18.70 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $505 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $4,660 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,900 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,413 drugs | Browse the Devoted PRIME San Antonio (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $0.00 | 25% | 25% | 25% |
• Number of Drugs per Tier: | 437 | 360 | 1016 | 903 | 697 |
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 Guadalupe, Texas: | 39 members | ||||
Number of Members enrolled in this plan in (H7993 - 004): | 706 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 Basic Premium | Part D Supplemental Premium | |
$18.70 | $0.00 | $18.70 | $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 | $4.70 | $9.30 | $14.00 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $4.70 | $9.30 | $14.00 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $18.70 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Drug plan deductible: $505.00 annual deductible | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• Acupuncture: Not covered | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Some coverage | |||||
More benefits | |||||
• Transportation services: Some coverage | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Some coverage | |||||
• Annual physical exams: Some coverage | |||||
• Telehealth: Some coverage | |||||
• 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: Some coverage | |||||
• Health Education: Some coverage | |||||
• 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: Some coverage | |||||
• Weight Management Programs: Some coverage | |||||
• Adult Day Health Services: Not covered | |||||
• Nutritional/Dietary Benefit: Some coverage | |||||
• 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): Not covered | |||||
• Counseling Services: Not covered |