2023 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Spirit Rx (HMO-POS) | ||||
Location: | Waukesha, Wisconsin Click to see other locations | ||||
Plan ID: | H5211 - 004 - 0 Click to see other plans | ||||
Member Services: | 1-715-221-9897 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 Spirit Rx (HMO-POS) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $230.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $4,660 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $1,200 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,763 drugs | Browse the Spirit Rx (HMO-POS) Formulary | |||
This plan has 6 drug tiers.
See cost-sharing for all pharmacies and tiers.
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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: | $9.00 | $20.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 345 | 1125 | 537 | 922 | 772 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 015574 PCN: ASPROD1 See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Waukesha, Wisconsin: | 16 members | ||||
Number of Members enrolled in this plan in Wisconsin: | 6,410 members | ||||
Number of Members enrolled in this plan in (H5211 - 004): | 6,511 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 4 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 | |
$230.00 | $121.40 | $82.80 | $25.80 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $65.50 | $76.30 | $87.00 | $97.80 | |
Total Monthly Premium with LIS (Parts C & D): | $186.90 | $197.70 | $208.40 | $219.20 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $230.00 | |||||
• Health plan premium: $121.40 | |||||
• Drug plan premium: $108.60 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Drug plan deductible: No annual deductible | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Routine care coverage | |||||
• Acupuncture: Not covered | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Not covered | |||||
More benefits | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Not covered | |||||
• 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: Some coverage | |||||
• Personal Emergency Response System (PERS): Not covered | |||||
• Medical Nutrition Therapy (MNT): Not covered | |||||
• Post discharge In-Home Medication Reconciliation: Not covered | |||||
• Re-admission Prevention: Some coverage | |||||
• 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: Some coverage | |||||
• Enhanced Disease Management: Some coverage | |||||
• Telemonitoring Services: Some coverage | |||||
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage | |||||
• Counseling Services: Not covered |