| 2020 Medicare Advantage Plan Details | |||||
|---|---|---|---|---|---|
| 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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| — 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 | |||||
