Great Plains Medicare Advantage Gold (HMO I-SNP)
Available to residents of Richland County, ND for 2026. Contract H8967, plan 002, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Richland County
- Plan website
- Browse the Great Plains Medicare Advantage Gold (HMO I-SNP) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $72.00 |
|---|---|
| — medical (Part C) part | $72.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $72.00?drug (Part D) part $0.00; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $2,750.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO I-SNP? |
| Special needs plan | Institutional SNP |
| Contract / plan | H8967-002-0 |
| Offered by | Great Plains Medicare Advantage |
| Parent organization | Sanford Health |
| Formulary drugs | 3,478 |
| Formulary exception tier | 4? |
| Pharmacy search | www.greatplainsmedicareadvantage.com |
| Member services | (877)701-0784TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H8967 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $30 copay |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $50 copay(authorization required) |
| Therapeutic radiology | $50 copay(authorization required) |
| Outpatient x-rays | $10 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $90 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | Not covered |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $185 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient hospital services | $50 copay(authorization required) |
| Outpatient observation | $100 copay |
| Ambulatory surgical center | $50 copay(authorization required) |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $50 per day for days 21–100 |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $0 copay |
| Physical therapy and speech-language therapy | $0 copay |
| Cardiac rehabilitation | $30 copay |
| Pulmonary rehabilitation | $20 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $185 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient mental health, individual session | $30 copay |
| Outpatient mental health, group session | $30 copay |
| Psychiatrist, individual session | $30 copay(referral required) |
| Psychiatrist, group session | $30 copay(referral required) |
| Partial hospitalization | $30 copay |
| Intensive outpatient program | $30 copay |
| Outpatient substance use, individual session | $30 copay |
| Outpatient substance use, group session | $30 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $150 copay |
| Air ambulance | 20% coinsurance |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay |
| Routine chiropractic care | $30 copay(limits apply) |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 0%–20% coinsurance |
| Routine foot care | $0 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | Not covered |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Comprehensive dental plan limit | $2,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay(limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | $0 copay(limits apply) |
| Bridges and other fixed prosthodontics | $0 copay(limits apply) |
| Oral and maxillofacial surgery | $0 copay(limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $30 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aid plan limit | $2,000 plan limit every year |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | Not covered |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $10.00 |
| Tier 3 | $45.00 |
| Tier 4 | $95.00 |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | n/a |
| Tier 2: Generic | $10.00 | $10.00 | n/a | $30.00 | $30.00 | n/a |
| Tier 3: Preferred Brand | $45.00 | $45.00 | n/a | $105.00 | $105.00 | n/a |
| Tier 4: Non-Preferred Drug | $95.00 | $95.00 | n/a | $285.00 | $285.00 | n/a |
| Tier 5: Specialty Tier | 33% | 33% | n/a | 33% | 33% | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 18 other ND counties
Benefits in plain text
Great Plains Medicare Advantage Gold (HMO I-SNP) (H8967-002-0) is a 2026 HMO I-SNP Medicare Advantage plan offered by Great Plains Medicare Advantage, available to residents of Richland County, ND.
The monthly premium is $72.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $72.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $2,750.00.
The drug deductible is $0.00.
It is a special needs plan (Institutional SNP).
The plan's formulary lists 3,478 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $10.00; tier 3: $45.00; tier 4: $95.00; tier 5: 33%; tier 6: $0.00.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.