2020 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | VIVA Medicare Extra Value (HMO D-SNP) | ||||
Location: | Baldwin, Alabama | ||||
Plan ID: | H0154 – 012 – 0 | ||||
Member Services: | 1-800-633-1542 TTY users 711 | ||||
— Enrollment Options — | |||||
Medicare Contact Information: | 1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048 |
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Call Medicare Solutions at 855-373-9484 / TTY 711 Monday ‐ Friday 8:30am — 10pm EST MULTIPLAN_GHHJTEXEN_ACCEPTED
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— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) | ||||
Annual Deductible: | $0 for people who qualify for both Medicare and Medicaid. | ||||
Annual Initial Coverage Limit (ICL): | $4,020 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: |
Dual-Eligible | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,105 drugs | ||||
This plan has 5 drug tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: |
25% | 25% | 25% | 25% | 25% |
• Number of Drugs per Tier: |
476 | 1482 | 304 | 249 | 594 |
Plan’s Pharmacy Search: | |||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Baldwin, Alabama: | 218 members | ||||
Number of Members enrolled in this plan in Alabama: | 18,529 members | ||||
Number of Members enrolled in this plan in (H0154 – 012): | 18,525 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: | Total Premium |
Part C Premium |
Part D Base Premium |
Part D Supplemental Premium |
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$28.70 | $0.00 | $28.70 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): | 100% Subsidy |
75% Subsidy |
50% Subsidy |
25% Subsidy |
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Monthly Part D Premium with LIS: | $0.00 | $7.20 | $14.40 | $21.50 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $7.20 | $14.40 | $21.50 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | Total monthly premium: $28.70 | ||||
Health plan premium: $0.00 | |||||
Drug plan premium: $28.70 | |||||
Standard Part B premium: $135.50 | |||||
Part B premium reduction: No | |||||
Deductible | Health plan deductible: $0 | ||||
Drug plan deductible: $434.00 | |||||
Estimated yearly costs | Estimated total yearly costs for care: $0.00 | ||||
Out-of-pocket max | Out-of-pocket max: $6,700 In-network | ||||
Doctor services | Primary doctor visit: $0 copay | ||||
Specialist visit: $0 or $10 per visit, Limits apply | |||||
Tests, labs, & imaging | Diagnostic tests & procedures: $0 or $0-50, Limits apply | ||||
Lab services: $0 copay, Limits apply | |||||
Diagnostic radiology services (like MRI): $0 or $10-50, Limits apply | |||||
Outpatient x-rays: $0 or $10, Limits apply | |||||
Emergency care: $0 or $90 per visit (always covered) | |||||
Urgent care: $0 or $0-40 per visit (always covered) | |||||
Hospital services | Inpatient hospital coverage: $0 or $245 per day for days 1 through 6 $0 per day for days 7 through 90, Limits apply | ||||
Outpatient hospital coverage: $0 or $0-175 per visit, Limits apply | |||||
Skilled nursing facility | Skilled nursing facility: $0 per day for days 1 through 20 $0 or $172 per day for days 21 through 59 $0 per day for days 60 through 100, Limits apply | ||||
Preventive services | Preventive services: $0 copay | ||||
Ambulance | Ground ambulance: $0 or $245 | ||||
Therapy services | Occupational therapy visit: $0 or $10, Limits apply | ||||
Physical therapy & speech & language therapy visit: $0 or $10, Limits apply | |||||
Mental health services | Outpatient group therapy with a psychiatrist: $0 or $10, Limits apply | ||||
Outpatient individual therapy with a psychiatrist: $0 or $10, Limits apply | |||||
Outpatient group therapy visit: $0 or $10, Limits apply | |||||
Outpatient individual therapy visit: $0 or $10, Limits apply | |||||
Opioid treatment services | Opioid treatment services: Covered | ||||
Other services | Durable medical equipment (like wheelchairs & oxygen): 0% or 20% per item, Limits apply | ||||
Prosthetics (like braces, artificial limbs): 0% or 20% per item, Limits apply | |||||
Diabetes supplies: $0 per item, Limits apply | |||||
Hearing | Hearing exam: $0 or $0-10 | ||||
Fitting/evaluation: Not covered | |||||
Hearing aids – Inner ear: Not covered | |||||
Hearing aids – Outer ear: Not covered | |||||
Hearing aids – Over the ear: Not covered | |||||
Preventive dental | Oral exam: $0 copay, Limits apply | ||||
Cleaning: $0 copay, Limits apply | |||||
Fluoride treatment: $0 copay, Limits apply | |||||
Dental x-rays: $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 | ||||
Contact lenses: $0 copay, Limits apply | |||||
Eyeglasses (frames & lenses): $0 copay, Limits apply | |||||
Eyeglass frames (only): $0 copay, Limits apply | |||||
Eyeglass lenses (only): $0 copay, Limits apply | |||||
Upgrades: $0 copay, Limits apply | |||||
More benefits | Fitness benefit: Limited coverage | ||||
Transportation services for non-emergency care: Any health-related locations: Not covered | |||||
Transportation services for non-emergency care: Plan-approved locations: Limited coverage | |||||
Over the counter drug benefits: Limited coverage | |||||
In-home support services: Not covered | |||||
Home and bathroom safety devices: Not covered | |||||
Meals for short duration: Not covered | |||||
Annual physical exams: Limited coverage | |||||
Telehealth: Not covered | |||||
Part B drugs | Chemotherapy drugs: 0% or 20%, Limits apply | ||||
Other Part B drugs: 0% or 20%, Limits apply |