2020 Medicare Advantage Plan Details
Medicare Plan Name: VIVA Medicare Plus (HMO)
Location: Baldwin, Alabama
Plan ID: H0154 – 015 – 1
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
Speak to a licensed sales agent to learn more and enroll.
Call Medicare Solutions at 855-373-9484 / TTY 711

Monday ‐ Friday 8:30am — 10pm EST
— Medicare Plan Features —
Monthly Premium: $0.00 (see Plan Premium Details below)
Annual Deductible: $150 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL): $4,020
Health Plan Type: Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): $6,700
Additional Gap Coverage? No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs: 4,184 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:
$0.00 $14.00 $47.00 45% 30%
Number of Drugs per
528 1809 322 702 823
Plan’s Pharmacy Search:
Plan Offers Mail Order? Yes
Number of Members enrolled in this plan in Baldwin, Alabama: 239 members
Number of Members enrolled in this plan in Alabama: 23,443 members
Number of Members enrolled in this plan in (H0154 – 015): 23,344 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
Part C
Part D Base
Part D Supplemental
$0.00 $0.00 $0.00 $0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): 100%
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 Total monthly premium: $0.00
Health plan premium: $0.00
Drug plan premium: $0.00
Standard Part B premium: $135.50
Part B premium reduction: No
Deductible Health plan deductible: $0
Drug plan deductible: $150.00
Estimated yearly costs Estimated total yearly costs for care: $3,798.00
Out-of-pocket max Out-of-pocket max: $6,700 In-network
Doctor services Primary doctor visit: $0 copay
Specialist visit: $40 per visit, Limits apply
Tests, labs, & imaging Diagnostic tests & procedures: $0-75, Limits apply
Lab services: 0-20%, Limits apply
Diagnostic radiology services (like MRI): $20-100, Limits apply
Outpatient x-rays: $20, Limits apply
Emergency care: $90 per visit (always covered)
Urgent care: $0-50 per visit (always covered)
Hospital services Inpatient hospital coverage: $290 per day for days 1 through 6 $0 per day for days 7 through 90, Limits apply
Outpatient hospital coverage: $0-290 per visit, Limits apply
Skilled nursing facility Skilled nursing facility: $0 per day for days 1 through 20 $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: $325
Therapy services Occupational therapy visit: $40, Limits apply
Physical therapy & speech & language therapy visit: $40, Limits apply
Mental health services Outpatient group therapy with a psychiatrist: $40, Limits apply
Outpatient individual therapy with a psychiatrist: $40, Limits apply
Outpatient group therapy visit: $40, Limits apply
Outpatient individual therapy visit: $40, Limits apply
Opioid treatment services Opioid treatment services: Covered
Other services Durable medical equipment (like wheelchairs & oxygen): 20% per item, Limits apply
Prosthetics (like braces, artificial limbs): 20% per item, Limits apply
Diabetes supplies: $0 per item, Limits apply
Hearing Hearing exam: $0-40
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
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: 20%, Limits apply
Other Part B drugs: 20%, Limits apply