Great Plains Medicare Advantage Gold (HMO I-SNP)
Available to residents of Custer County, NE for 2027. Contract H7511, plan 004, 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 Custer County
- Plan website
- Browse the Great Plains Medicare Advantage Gold (HMO I-SNP) 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 NE plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $119.00 |
|---|---|
| — medical (Part C) part | $80.00 |
| — drug (Part D) part | $39.00? |
| Monthly premium with full Extra Help (LIS) | $94.40?drug (Part D) part $14.40; 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 | $3,750.00? |
| Drug deductible | $300.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO I-SNP? |
| Special needs plan | Institutional SNP |
| Contract / plan | H7511-004-0 |
| Offered by | Great Plains Medicare Advantage |
| Parent organization | Sanford Health |
| Formulary tiers | 6 |
| 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)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H7511 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $0–$30 copay |
| Additional telehealth services | $0–$200 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 | $0 copay(authorization required) |
| Lab services | 20% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$50 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $10 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $90 copay |
| Urgent care | $0–$30 copay |
| Worldwide emergency coverage | Not covered |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $300 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient hospital services | $0–$200 copay(authorization required) |
| Outpatient observation | $0–$200 copay |
| Ambulatory surgical center | $0–$200 copay(authorization required) |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $100 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 | $300 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 | $0 copay |
| Intensive outpatient program | $0 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(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| 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(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| 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 | $30 copay |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| 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 |
| Maxillofacial prosthetics | Not covered |
| Implants | $0 copay(limits apply) |
| Bridges and other fixed prosthodontics | $0 copay(limits apply) |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay |
| 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) | Not covered |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| 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, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $8.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 30% |
| Tier 5 · Specialty Tier | 30% |
| Tier 6 · Select Care Drugs | $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 | $8.00 | $8.00 | n/a | $24.00 | $24.00 | n/a |
| Tier 3: Preferred Brand | 25% | 25% | n/a | 25% | 25% | n/a |
| Tier 4: Non-Preferred Drug | 30% | 30% | n/a | 30% | 30% | n/a |
| Tier 5: Specialty Tier | 30% | 30% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | 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.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Managing Chronic (Long Term) Conditions | ||
| Special Needs Plan (SNP) Care Management · C07 | 5 out of 5 stars for Special Needs Plan (SNP) Care Management | 5 out of 5 stars for Special Needs Plan (SNP) Care Management |
| Care for Older Adults – Medication Review · C08 | 2 out of 5 stars for Care for Older Adults – Medication Review | 5 out of 5 stars for Care for Older Adults – Medication Review |
| Care for Older Adults - Functional Status Assessment · C09 | 2 out of 5 stars for Care for Older Adults - Functional Status Assessment | new measure |
| Transitions of Care · C19 | 1 out of 5 stars for Transitions of Care | not enough data |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Drug Plan Quality Improvement · D04 | 3 out of 5 stars for Drug Plan Quality Improvement | 3 out of 5 stars for Drug Plan Quality Improvement |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | 4 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 5 out of 5 stars for Medication Adherence for Diabetes Medications | 5 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 5 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 5 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 5 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 4 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 4 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H7511 shares it.
Also available in 55 other NE counties
- Adams
- Antelope
- Boone
- Boyd
- Brown
- Buffalo
- Burt
- Butler
- Cass
- Cedar
- Clay
- Colfax
- Cuming
- Dakota
- Dixon
- Dodge
- Douglas
- Fillmore
- Franklin
- Furnas
- Gage
- Gosper
- Hall
- Hamilton
- Harlan
- Holt
- Howard
- Jefferson
- Johnson
- Kearney
- Knox
- Lancaster
- Madison
- Merrick
- Nance
- Nemaha
- Nuckolls
- Otoe
- Pawnee
- Phelps
- Pierce
- Platte
- Polk
- Rock
- Saline
- Sarpy
- Saunders
- Seward
- Sherman
- Stanton
- Valley
- Washington
- Wayne
- Webster
- York
Benefits in plain text
Great Plains Medicare Advantage Gold (HMO I-SNP) (H7511-004-0) is a 2027 HMO I-SNP Medicare Advantage plan offered by Great Plains Medicare Advantage, available to residents of Custer County, NE.
The monthly premium is $119.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $94.40.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $3,750.00.
The drug deductible is $300.00. Tier 1, 2 and 6 exempt.
It is a special needs plan (Institutional SNP).
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): 25%; tier 4 (Non-Preferred Drug): 30%; tier 5 (Specialty Tier): 30%; tier 6 (Select Care Drugs): $0.00.
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.