True West Rx 5 (PPO)
Available to residents of Bonner County, ID for 2027. Contract H8267, plan 005, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Bonner County
- Plan website
- Browse the True West Rx 5 (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every ID plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $199.00 |
|---|---|
| — medical (Part C) part | $130.50 |
| — drug (Part D) part | $68.50? |
| Monthly premium with full Extra Help (LIS) | $153.50?drug (Part D) part $23.00; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $8,000.00? |
| In- and out-of-network out-of-pocket maximum | $10,500.00 |
| Drug deductible | $700.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H8267-005-0 |
| Offered by | Range Health |
| Parent organization | Gemstone Holdings, Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | rangehealth.com/findapharmacy |
| Member services | (833)574-6031TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H8267 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | 50% coinsurance |
| Specialist | $50 copay | 50% coinsurance |
| Other health care professional | $0–$50 copay(authorization required) | 50% coinsurance |
| Additional telehealth services | $0–$50 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | 50% coinsurance |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $30 copay(authorization required) | 50% coinsurance |
| Lab services | $0 copay(authorization required) | 50% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$250 copay(authorization required) | 50% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization required) | 50% coinsurance |
| Outpatient x-rays | $0 copay(authorization required) | 50% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $115 copay | — |
| Urgent care | $40 copay | — |
| Worldwide emergency coverage | $115 copay · $10,000 plan limit | — |
| Worldwide urgent care | $40 copay · $10,000 plan limit | — |
| Worldwide emergency transportation | $325 copay; 20% coinsurance | — |
| Hospital care | ||
| Inpatient hospital stay | $415 per day for days 1–5; $0 per day for days 6–90(authorization required) | $450 per day for days 1–10; $0 per day for days 11–90 |
| Outpatient hospital services | $0–$495 copay; 20% coinsurance(authorization required) | 50% coinsurance |
| Outpatient observation | $425 copay(authorization required) | 50% coinsurance |
| Ambulatory surgical center | $0–$300 copay; 20% coinsurance(authorization required) | 50% coinsurance |
| Outpatient blood services | $0 copay | 50% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–70; $0 per day for days 71–100(authorization required) | 50% coinsurance for days 1–100 |
| Home health care | $0 copay | 50% coinsurance |
| Kidney dialysis | 20% coinsurance | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $30 copay | 50% coinsurance |
| Physical therapy and speech-language therapy | $30 copay | 50% coinsurance |
| Cardiac rehabilitation | $30 copay | $30 copay |
| Pulmonary rehabilitation | $25 copay | 50% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $415 per day for days 1–5; $0 per day for days 6–90(authorization required) | $450 per day for days 1–10; $0 per day for days 11–90 |
| Outpatient mental health, individual session | $20 copay | 50% coinsurance |
| Outpatient mental health, group session | $20 copay | 50% coinsurance |
| Psychiatrist, individual session | $50 copay | 50% coinsurance |
| Psychiatrist, group session | $50 copay | 50% coinsurance |
| Partial hospitalization | $115 copay(authorization required) | 50% coinsurance |
| Intensive outpatient program | $120 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, individual session | $20 copay | 50% coinsurance |
| Outpatient substance use, group session | $20 copay | 50% coinsurance |
| Opioid treatment program | $0 copay | 50% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | $325 copay(authorization required) | $325 copay |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 18% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 18% coinsurance(authorization required) | 50% coinsurance |
| Medical supplies | 18% coinsurance(authorization required) | 50% coinsurance |
| Diabetes supplies | $0 copay | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance | 50% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay | 50% coinsurance |
| Routine chiropractic care | Not covered | — |
| Acupuncture | Not covered | — |
| Foot exams and treatment (Medicare-covered) | $30 copay | 50% coinsurance |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $30 copay | 50% coinsurance |
| Preventive dental plan limit | $500 plan limit every year | — |
| Other diagnostic dental services | Not covered | — |
| Other preventive dental services | Not covered | — |
| Restorative services (fillings, crowns) | Not covered | — |
| Endodontics (root canals) | Not covered | — |
| Periodontics (gum disease) | Not covered | — |
| Dentures and other removable prosthodontics | Not covered | — |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | Not covered | — |
| Oral and maxillofacial surgery | Not covered | — |
| Orthodontics | Not covered | — |
| Adjunctive general services | Not covered | — |
| Vision? | ||
| Eye exam (Medicare-covered) | $30 copay(authorization required) | 50% coinsurance |
| Routine eye exam | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Contact lenses | $0–$35 copay(authorization required, limits apply) | $0–$35 copay |
| Eyeglasses (frames and lenses) | $35 copay(authorization required, limits apply) | 50% coinsurance |
| Eyeglass lenses | Not covered | — |
| Eyeglass frames | Not covered | — |
| Eyewear upgrades | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $30 copay | 50% coinsurance |
| Routine hearing exam | $0 copay(limits apply) | 90% coinsurance |
| Hearing aid fitting and evaluation | $0 copay | 90% coinsurance |
| Hearing aids (all types) | $499–$999 copay(limits apply) | 90% coinsurance |
| 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) | 0%–50% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–50% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–50% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Not covered | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | 90% coinsurance |
| 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, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $8.00 |
| Tier 3 · Preferred Brand | 24% |
| Tier 4 · Non-Preferred Drug | 26% |
| Tier 5 · Specialty Tier | 25% |
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 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $8.00 | $8.00 | $8.00 | $24.00 | $24.00 | $24.00 |
| Tier 3: Preferred Brand | 24% | 24% | 24% | 24% | 24% | 24% |
| Tier 4: Non-Preferred Drug | 26% | 26% | 26% | 26% | 26% | 26% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Also available in 2 other ID counties
Benefits in plain text
True West Rx 5 (PPO) (H8267-005-0) is a 2027 PPO Medicare Advantage plan offered by Range Health, available to residents of Bonner County, ID.
The monthly premium is $199.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $153.50.
Its in-network out-of-pocket maximum is $8,000.00.
The combined in- and out-of-network out-of-pocket maximum is $10,500.00.
The drug deductible is $700.00. Tier 1 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $8.00; tier 3 (Preferred Brand): 24%; tier 4 (Non-Preferred Drug): 26%; tier 5 (Specialty Tier): 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.