2024 Medicare Advantage Plan Details | |||||
---|---|---|---|---|---|
Medicare Plan Name: | Medica Advantage Value (PPO) | ||||
Location: | Howard, Nebraska Click to see other locations | ||||
Plan ID: | H8889 - 010 - 0 Click to see other plans | ||||
Member Services: | 1-952-992-2134 TTY users 711 | ||||
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 Medica Advantage Value (PPO) benefit details
![]() | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $5,030 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,900 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,507 drugs | Browse the Medica Advantage Value (PPO) 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 | $14.00 | $47.00 | 50% | 33% |
• Number of Drugs per Tier: | 395 | 856 | 753 | 778 | 725 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 003858 PCN: MD See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Howard, Nebraska: | 14 members | ||||
Number of Members enrolled in this plan in Nebraska: | 620 members | ||||
Number of Members enrolled in this plan in (H8889 - 010): | 1,503 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 3 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 Base Premium | Part D Supplemental Premium | |
$0.00 | $0.00 | $0.00 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | $0.00 | ||||
Total Monthly Premium with LIS (Parts C & D): | $0.00 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $0 | |||||
• 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) | |||||
• $3,900 In and Out-of-network $3,900 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: $0 copay | |||||
• Primary Out-of-network: $25 copay per visit | |||||
• Specialist In-network: $35 copay per visit | |||||
• Specialist Out-of-network: $50 copay per visit | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures In-network: $0-100 copay (authorization required) | |||||
• Diagnostic tests and procedures Out-of-network: $0-100 copay (authorization required) | |||||
• Lab services In-network: $0 copay (authorization required) | |||||
• Lab services Out-of-network: $0 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) In-network: $0-100 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) Out-of-network: $0-100 copay (authorization required) | |||||
• Outpatient x-rays In-network: $15 copay (authorization required) | |||||
• Outpatient x-rays Out-of-network: $15 copay (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $120 copay per visit (always covered) | |||||
• Urgent care: $0-50 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• In-network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Out-of-network: $370 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• In-network: $0-375 copay per visit (authorization required) | |||||
• Out-of-network: $0-425 copay per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• In-network: $0 per day for days 1 through 20 $203 per day for days 21 through 39 $0 per day for days 40 through 100 (authorization required) | |||||
• Out-of-network: $100 per day for days 1 through 20 $203 per day for days 21 through 39 $0 per day for days 40 through 100 (authorization required) | |||||
Preventive care | |||||
• In-network: $0 copay | |||||
• Out-of-network: $0 copay | |||||
Ground ambulance | |||||
• In-network: $250 copay | |||||
• Out-of-network: $250 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit In-network: $35 copay | |||||
• Occupational therapy visit Out-of-network: $50 copay | |||||
• Physical therapy and speech and language therapy visit In-network: $35 copay | |||||
• Physical therapy and speech and language therapy visit Out-of-network: $50 copay | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric In-network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Inpatient hospital - psychiatric Out-of-network: $370 per day for days 1 through 5 $0 per day for days 6 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: $50 copay | |||||
• Outpatient individual therapy visit with a psychiatrist In-network: $35 copay | |||||
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $50 copay | |||||
• Outpatient group therapy visit In-network: $35 copay | |||||
• Outpatient group therapy visit Out-of-network: $50 copay | |||||
• Outpatient individual therapy visit In-network: $35 copay | |||||
• Outpatient individual therapy visit Out-of-network: $50 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: 0-30% coinsurance per item | |||||
Hearing | |||||
• Hearing exam In-network: $0-25 copay | |||||
• Hearing exam Out-of-network: $25-40 copay | |||||
• Fitting/evaluation In-network: $0 copay (limits apply) | |||||
• Fitting/evaluation Out-of-network: $0 copay (limits apply) | |||||
• Hearing aids In-network: $549-799 copay | |||||
• Hearing aids Out-of-network: $549-799 copay | |||||
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 In-network: $0 copay (limits apply) | |||||
• Fluoride treatment Out-of-network: $0 copay (limits apply) | |||||
• 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 In-network: $0 copay (limits apply) | |||||
• Non-routine services Out-of-network: $0 copay (limits apply) | |||||
• Diagnostic services In-network: $0 copay (limits apply) | |||||
• Diagnostic services Out-of-network: $0 copay (limits apply) | |||||
• Restorative services In-network: $0 copay (limits apply) | |||||
• Restorative services Out-of-network: $0 copay (limits apply) | |||||
• Endodontics In-network: $0 copay (limits apply) | |||||
• Endodontics Out-of-network: $0 copay (limits apply) | |||||
• Periodontics In-network: $0 copay (limits apply) | |||||
• Periodontics Out-of-network: $0 copay (limits apply) | |||||
• Extractions In-network: $0 copay (limits apply) | |||||
• Extractions Out-of-network: $0 copay (limits apply) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: $0 copay (limits apply) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: $0 copay (limits apply) | |||||
Vision | |||||
• Routine eye exam In-network: $0 copay (limits apply) | |||||
• Routine eye exam Out-of-network: $0 copay (limits apply) | |||||
• Other In-network: $0 copay (limits apply) | |||||
• Other Out-of-network: $0 copay (limits apply) | |||||
• 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 In-network: $0 copay (limits apply) | |||||
• Upgrades Out-of-network: $0 copay (limits apply) | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• 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 | |||||
• Fitness Benefit: Some coverage | |||||
• In-Home Support Services: Not covered | |||||
• Bathroom Safety Devices: Not covered | |||||
• Health Education: Not covered | |||||
• 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: 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 | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment In-network: $35 copay | |||||
• Foot exams and treatment Out-of-network: $50 copay | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Part B Insulin drugs In-network: $35 copay (authorization required) | |||||
• Part B Insulin drugs Out-of-network: $35 copay or 0-30% coinsurance (authorization required) | |||||
• Chemotherapy In-network: 0-20% coinsurance (authorization required) | |||||
• Chemotherapy Out-of-network: $35 copay or 0-30% coinsurance (authorization required) | |||||
• Other Part B drugs In-network: 0-20% coinsurance (authorization required) | |||||
• Other Part B drugs Out-of-network: $35 copay or 0-30% coinsurance (authorization required) |