2021 Braven Medicare Choice (PPO) - H0885-001-0 In NJ Plan ...

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2021 Medicare Advantage Plan Benefit Details for the Braven Medicare Choice (PPO) - H0885-001-0 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:Braven Medicare Choice (PPO)
Location:Union, New Jersey Click to see other locations
Plan ID:H0885 - 001 - 0 Click to see other plans
Member Services:1-833-272-8360 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 Braven Medicare Choice (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Rx Deductible:$150 (Tier 1 and 2 excluded from the Deductible.)
Annual Rx Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Rx Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:2,801 drugsBrowse the Braven Medicare Choice (PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.
This plan offers select insulin at a $35 copay. Learn more.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:$0.00$10.00$47.00$100.0030%
• Number of Drugs per Tier:118635701674673
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Union, New Jersey:796 members
Number of Members enrolled in this plan in (H0885 - 001):13,575 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: $150.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10,000 In and Out-of-network$6,700 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 In-network: $0 copay
• Primary Out-of-network: $10 copay per visit
• Specialist In-network: $20 copay per visit (authorization required)
• Specialist Out-of-network: $30 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $0-90 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: $50-110 copay (authorization required)
• Lab services In-network: $0-30 copay (authorization required)
• Lab services Out-of-network: $20-50 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $0-150 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: $60-175 copay (authorization required)
• Outpatient x-rays In-network: $25 copay (authorization required)
• Outpatient x-rays Out-of-network: $40 copay (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: $320 per day for days 1 through 5$0 per day for days 6 through 90$0 per day for days 91 and beyond (authorization required)
• Out-of-network: $320 per day for days 1 through 5$0 per day for days 6 and beyond (authorization required)
Outpatient hospital coverage
• In-network: $295 copay per visit (authorization required)
• Out-of-network: $350-395 copay per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20$178 per day for days 21 through 100 (authorization required)
• Out-of-network: 20% per day for days 1 through 100 (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: $10 copay
Ground ambulance
• In-network: $250 copay
• Out-of-network: $250 copay or 20% coinsurance
Rehabilitation services
• Occupational therapy visit In-network: $20 copay (authorization required)
• Occupational therapy visit Out-of-network: $30 copay (authorization required)
• Physical therapy and speech and language therapy visit In-network: $20 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: $30 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $320 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: $320 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: $50 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $50 copay (authorization required)
• Outpatient group therapy visit In-network: $40 copay (authorization required)
• Outpatient group therapy visit Out-of-network: $50 copay (authorization required)
• Outpatient individual therapy visit In-network: $40 copay (authorization required)
• Outpatient individual therapy visit Out-of-network: $50 copay (authorization required)
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: 20% 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: 20% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay (authorization required)
• Diabetes supplies Out-of-network: 20% coinsurance per item (authorization required)
Hearing
• Hearing exam In-network: $20 copay
• Hearing exam Out-of-network: $30 copay
• Fitting/evaluation In-network: $0 copay (limits apply)
• Fitting/evaluation Out-of-network: $30 copay (limits apply)
• Hearing aids In-network: $0 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 In-network: $0 copay (limits apply)
• Fluoride treatment Out-of-network: $0 copay (limits apply)
• 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 In-network: 50% coinsurance (limits apply)
• Non-routine services Out-of-network: 50% coinsurance (limits apply)
• Diagnostic services In-network: 50% coinsurance (limits apply)
• Diagnostic services Out-of-network: 50% coinsurance (limits apply)
• Restorative services In-network: 50% coinsurance (limits apply)
• Restorative services Out-of-network: 50% coinsurance (limits apply)
• Endodontics In-network: 50% coinsurance (limits apply)
• Endodontics Out-of-network: 50% coinsurance (limits apply)
• Periodontics In-network: 50% coinsurance (limits apply)
• Periodontics Out-of-network: 50% coinsurance (limits apply)
• Extractions In-network: 50% coinsurance (limits apply)
• Extractions Out-of-network: 50% coinsurance (limits apply)
• 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: $30 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 In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $0 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $20 copay
• Foot exams and treatment Out-of-network: $30 copay
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 20% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 20% coinsurance (authorization required)

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