2020 Allwell Medicare (PPO) - H6348-001-0 In IN Plan Benefits ...

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2020 Medicare Advantage Plan Benefit Details for the Allwell Medicare (PPO) - H6348-001-0 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
2020 Medicare Advantage Plan Details
Medicare Plan Name:Allwell Medicare (PPO)
Location:Shelby, Indiana Click to see other locations
Plan ID:H6348 - 001 - 0 Click to see other plans
Member Services:1-855-766-1541 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 visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for information on all of your options. TTY users 1-877-486-2048or contact your local SHIP for assistance
Email a copy of the Allwell Medicare (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$19.00 (see Plan Premium Details below)
Annual Rx Deductible:$200 (Tier 1, 2, 3 and 6 excluded from the Deductible.)
Annual Rx Initial Coverage Limit (ICL):$4,020
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,500
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Rx Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:4,030 drugsBrowse the Allwell Medicare (PPO) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:$0.00$5.00$37.00$90.0029%
• Number of Drugs per Tier:2799098351133740
Plan's Pharmacy Search:http://allwell.mhsindiana.com/findadoctor
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 004336 PCN: MEDDADV See BIN/PCNs for all plans
Number of Members enrolled in this plan in Shelby, Indiana:less than 10 members
Number of Members enrolled in this plan in Indiana:85 members
Number of Members enrolled in this plan in (H6348 - 001):110 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: Insufficient data to rate this plan.
• Member Experience Rating: Insufficient data to rate this plan.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔TotalPremiumPart CPremiumPart D BasicPremiumPart D SupplementalPremium
$19.00$0.00$19.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%Subsidy75%Subsidy50%Subsidy25%Subsidy
Monthly Part D Premium with LIS:$0.00$4.70$9.50$14.20
Total Monthly Premium with LIS (Parts C & D): $0.00$4.70$9.50$14.20
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $19
• 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: $200.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $9,000 In and Out-of-network$5,500 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $5 copay per visit
• Primary Out-of-network: $25 copay per visit
• Specialist In-network: $40 copay per visit
• Specialist Out-of-network: $60 copay per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $25 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required)
• Lab services In-network: $5-15 copay (authorization required)
• Lab services Out-of-network: 40% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: 20% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required)
• Outpatient x-rays In-network: $0-35 copay (authorization required)
• Outpatient x-rays Out-of-network: 40% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $300 per day for days 1 through 6$0 per day for days 7 through 90 (authorization required)
• Out-of-network: 40% per stay (authorization required)
Outpatient hospital coverage
• In-network: $325 copay per visit (authorization required)
• Out-of-network: 40% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20$170 per day for days 21 through 100 (authorization required)
• Out-of-network: 40% per stay (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: 40% coinsurance
Ground ambulance
• In-network: $295 copay
• Out-of-network: $295 copay
Rehabilitation services
• Occupational therapy visit In-network: $35 copay (authorization required)
• Occupational therapy visit Out-of-network: 40% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit In-network: $35 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: 40% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $300 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 40% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay
• Outpatient group therapy visit with a psychiatrist Out-of-network: 40% coinsurance
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 40% coinsurance
• Outpatient group therapy visit In-network: $40 copay
• Outpatient group therapy visit Out-of-network: 40% coinsurance
• Outpatient individual therapy visit In-network: $40 copay
• Outpatient individual therapy visit Out-of-network: 40% coinsurance
Opioid treatment program services
• In-network: $40.00 copay
• Out-of-network: 40% coinsurance
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: 40% 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: 40% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay
• Diabetes supplies Out-of-network: 0-40% coinsurance per item
Dialysis
• 20% coinsurance
Hearing
• Hearing exam In-network: $40 copay
• Hearing exam Out-of-network: $60 copay
• Fitting/evaluation In-network: $0 copay (limits apply)
• Fitting/evaluation Out-of-network: $60 copay (limits apply)
• Hearing aids In-network: $0-1,580 copay (limits apply)
• Hearing aids Out-of-network: $0 copay (limits apply)
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: Not covered
• 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: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $60 copay (limits apply)
• Other: Not covered
• 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: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $40 copay
• Foot exams and treatment Out-of-network: $60 copay
• Routine foot care In-network: $40 copay
• Routine foot care Out-of-network: $60 copay
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 40% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 40% coinsurance (authorization required)
Package #1
• Monthly Premium: $13.70
• Deductible:
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: Not covered
• 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: 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: Some coverage
• 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

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