2021 Amerivantage Classic Plus (HMO) - H8849-008-2 In TX Plan ...
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 drugs | Browse the Amerivantage Classic Plus (HMO) Formulary | |||
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. ![]() | |||||
| Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
| • Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $12.00 | $42.00 | $95.00 | 33% |
| • Number of Drugs per Tier: | 302 | 607 | 940 | 1055 | 710 |
| 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: ❔ | TotalPremium | Part CPremium | Part D BasicPremium | Part D SupplementalPremium | |
| $0.00 | $0.00 | $0.00 | $0.00 | ||
| Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100%Subsidy | 75%Subsidy | 50%Subsidy | 25%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) |
- Top
Từ khóa » Cms H8849
-
2021 Amerivantage Dual Coordination Plus (HMO D-SNP)
-
Amerivantage-Classic-Plus-HMO H8849:008-1
-
[PDF] 0255-H8849_008-002_TX_HMO Summary Of Benefits - Ribbon Health
-
Amerivantage-Classic-Plus-HMO H8849:008-2
-
Amerivantage-Plus-HMO H8849:007-0 | Alight Retiree Health ...
-
[PDF] Providers – Amerigroup
-
2022 Amerigroup | Amerivantage Classic Plus (HMO) | US News
-
Amerivantage Dual Coordination Plus (HMO D-SNP) - Healthpocket
-
[XLS] Contract Year 2022 Dual Eligible Special Needs Plan Integration ...
-
[Product Groups] - Hexis UK
-
[PDF] Contracted MAP DSNP 2022 - TMHP
-
Explore Your Medicare Coverage Options
-
Summary Of Benefits For 2021 Amerivantage Classic Plus (HMO)
-
Amerivantage Classic Plus (HMO) | Medicare Advantage Plan ...
