2021 Amerivantage Classic Plus (HMO) - H8849-008-2 In TX Plan ...

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2021 Medicare Advantage Plan Benefit Details for the Amerivantage Classic Plus (HMO) - H8849-008-2 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
2021 Medicare Advantage Plan Details
Medicare Plan Name:Amerivantage Classic Plus (HMO)
Location:Navarro, Texas Click to see other locations
Plan ID:H8849 - 008 - 2 Click to see other plans
Member Services:1-833-713-1304 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 Amerivantage Classic Plus (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Rx Deductible:$0
Annual Rx Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$2,500
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Rx Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,704 drugsBrowse the Amerivantage Classic Plus (HMO) 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:$5.00$12.00$42.00$95.0033%
• Number of Drugs per Tier:3026079401055710
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Navarro, Texas:135 members
Number of Members enrolled in this plan in (H8849 - 008):23,005 members
Plan’s Summary Star Rating: New plan - No summary rating as of yet.
• Customer Service Rating: New plan - not yet rated.
• Member Experience Rating: New plan - not yet rated.
• Drug Cost Accuracy Rating: New plan - not yet rated.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔TotalPremiumPart CPremiumPart D BasicPremiumPart D SupplementalPremium
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%Subsidy75%Subsidy50%Subsidy25%Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D): $0.00$0.00$0.00$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)
• $2,500 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: $0 copay
• Specialist: $20 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-50 copay (authorization and referral required)
• Lab services: $0 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $25-75 copay (authorization and referral required)
• Outpatient x-rays: $0 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $120 copay per visit (always covered)
• Urgent care: $35 copay per visit (always covered)
Inpatient hospital coverage
• $225 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
Outpatient hospital coverage
• $0-215 copay per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20$140 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $260 copay
Rehabilitation services
• Occupational therapy visit: $30 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $30 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $225 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient group therapy visit: $40 copay (authorization and referral required)
• Outpatient individual therapy visit: $40 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Hearing
• Hearing exam: $20 copay (authorization and referral required)
• Fitting/evaluation: $0 copay (limits apply, authorization and referral required)
• Hearing aids: $0 copay (limits apply, authorization required)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: $0 copay (limits apply)
• Diagnostic services: $0 copay (limits apply)
• Restorative services: $0 copay (limits apply)
• Endodontics: $0 copay (limits apply)
• Periodontics: $0 copay (limits apply)
• Extractions: $0 copay (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered (authorization required)
Transportation
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0-20 copay (authorization and referral required)
• Routine foot care: $0 copay (authorization and referral required)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)

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