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2012 Medicare Advantage Plan Benefit Details for the Humana Gold Plus H2649-004 (HMO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2012 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Plus H2649-004 (HMO)
Location:Johnson, Missouri     Click to see other locations
Plan ID:H2649 - 004 - 0     Click to see other plans
Member Services:1-800-457-4708 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 go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Humana Gold Plus H2649-004 (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$20.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,930
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Additional Gap Coverage?Some Generics,
Few Brands
Total Number of Formulary Drugs:4,004 drugsBrowse the Humana Gold Plus H2649-004 (HMO) Formulary
This plan has 4 drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$5.00$40.00$75.0033% 
• Number of Drugs per
  Tier:		14339031340328
Plan's Pharmacy Search:http://www.humana.com/Medicare/medicare_prescription_drugs
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in (H2649 - 004):23,489 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
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
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$20 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
$3 400 out-of-pocket limit for Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network hospitals and specialists (for certain benefits).
** Extra Benefits **
Over-the-Counter Items
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
Transportation
This plan does not cover supplemental routine transportation.
** Important Information **
Premium and Other Important Information
$20 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
$3 400 out-of-pocket limit for Medicare-covered services.
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network hospitals and specialists (for certain benefits).
** Inpatient Care **
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 7: $225 copay per day
Days 8 - 90: $0 copay per day
$0 copay for each additional hospital day.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
Inpatient Mental Health Care
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
For Medicare-covered hospital stays:
Days 1 - 7: $200 copay per day
Days 8 - 90: $0 copay per day
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
Skilled Nursing Facility (SNF)
Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For SNF stays:
Days 1 - 14: $0 copay per day
Days 15 - 21: $50 copay per day
Days 22 - 100: $125 copay per day
Home Health Care
Authorization rules may apply.
$5 copay for each Medicare-covered home health visit
Hospice
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.
** Outpatient Care **
Doctor Office Visits
Authorization rules may apply.
$10 copay for each primary care doctor visit for Medicare-covered benefits.
$35 copay for each in-area network urgent care Medicare-covered visit
$35 copay for each specialist visit for Medicare-covered benefits.
Chiropractic Services
$10 copay for each Medicare-covered visit
$10 copay for up to 24 supplemental routine visit(s) every year
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
Podiatry Services
Authorization rules may apply.
$35 copay for each Medicare-covered visit
Medicare-covered podiatry benefits are for medically-necessary foot care.
Outpatient Mental Health Care
Authorization rules may apply.
$35 copay for each Medicare-covered individual therapy visit
$35 copay for each Medicare-covered group therapy visit
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist
$35 copay for each Medicare-covered group therapy visit with a psychiatrist
$35 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care
Authorization rules may apply.
$50 copay for Medicare-covered individual visits
$50 copay for Medicare-covered group visits
Outpatient Services/Surgery
Authorization rules may apply.
$225 copay for each Medicare-covered ambulatory surgical center visit
$0 to $225 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
Ambulance Services
Authorization rules may apply.
$100 copay for Medicare-covered ambulance benefits.
Emergency Care
$65 copay for Medicare-covered emergency room visits
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.
Urgently Needed Care
$10 to $35 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation Services
Authorization rules may apply.
$35 copay for Medicare-covered Occupational Therapy visits
$35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits
** Outpatient Medical Services and Supplies **
Durable Medical Equipment
Authorization rules may apply.
20% of the cost for Medicare-covered items
Prosthetic Devices
Authorization rules may apply.
20% of the cost for Medicare-covered items
Diabetes Programs and Supplies
Authorization rules may apply.
$0 copay for Diabetes self-management training
0% to 20% of the cost for Diabetes monitoring supplies
0% of the cost for Therapeutic shoes or inserts
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services'
Authorization rules may apply.
$0 to $35 copay for Medicare-covered lab services
$0 to $50 copay for Medicare-covered diagnostic procedures and tests
$10 to $35 copay for Medicare-covered X-rays
$10 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
$35 copay for Medicare-covered therapeutic radiology services
** Preventive Services **
Cardiac and Pulmonary Rehabilitation Services
Authorization rules may apply.
$0 to $35 copay for Medicare-covered Cardiac Rehabilitation Services
$0 to $35 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$35 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services and Wellness/Education Programs
$0 copay for all preventive services covered under Original Medicare at zero cost sharing:
  • Abdominal Aortic Aneurysm screening
  • Bone Mass Measurement
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine
  • HIV Screening
  • Breast Cancer Screening (Mammogram)
  • Medical Nutrition Therapy Services
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine
  • Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
  • Smoking Cessation (Counseling to stop smoking)
  • Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
    • HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.
    The plan covers the following supplemental education/wellness programs:
  • Written health education materials including Newsletters
  • Additional Smoking Cessation
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Kidney Disease and Conditions
    Authorization rules may apply.
    0% to 20% of the cost for renal dialysis
    $0 copay for kidney disease education services
    Outpatient Prescription Drugs
    0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs).
    20% of the cost for Part B-covered chemotherapy drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp on the web.
    Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.
    • The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from Humana Gold Plus H2649-004 (HMO) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    If you request a formulary exception for a drug and Humana Gold Plus H2649-004 (HMO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $75 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $15 copay for a three-month (90-day) supply of drugs in this tier
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $225 copay for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (34-day) supply of drugs in this tier
  • $40 copay for a one-month (34-day) supply of drugs in this tier
  • $75 copay for a one-month (34-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (34-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $75 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $110 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $215 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $5 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $75 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $15 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $225 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    The plan covers some formulary generics (10%-64% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
    You pay the following:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $75 copay for a one-month (30-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier
  • $120 copay for a three-month (90-day) supply of select drugs covered in this tier
  • $225 copay for a three-month (90-day) supply of select drugs covered in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (34-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (34-day) supply of select drugs covered in this tier
  • $75 copay for a one-month (34-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (34-day) supply of select drugs covered in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $75 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $110 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $215 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $75 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $120 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $225 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    After your total yearly drug costs reach $2 930 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700.
    Please contact the plan for a complete list of drugs covered through the gap.
    After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
    • Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Humana Gold Plus H2649-004 (HMO).
    You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $75 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $75 copay for a one-month (30-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Dental Services
    $0 copay for the following preventive dental benefits:
  • up to 1 oral exam(s) every year
  • up to 1 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • $35 copay for Medicare-covered dental benefits
    Plan offers additional comprehensive dental benefits.
    Hearing Services
    Authorization rules may apply.
    In general supplemental routine hearing exams and hearing aids not covered.
  • $35 copay for Medicare-covered diagnostic hearing exams
    • ** Additional Benefits **
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
  • $20 copay for up to 1 pair(s) of glasses every year
    • Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    Transportation
    This plan does not cover supplemental routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    For Medicare-covered hospital stays:
    Days 1 - 7: $225 copay per day
    Days 8 - 90: $0 copay per day
    $0 copay for each additional hospital day.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    ** Outpatient Care **
    Doctor Office Visits
    Authorization rules may apply.
    $10 copay for each primary care doctor visit for Medicare-covered benefits.
    $35 copay for each in-area network urgent care Medicare-covered visit
    $35 copay for each specialist visit for Medicare-covered benefits.
    Outpatient Services/Surgery
    Authorization rules may apply.
    $225 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $225 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $100 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered items
    'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services'
    Authorization rules may apply.
    $0 to $35 copay for Medicare-covered lab services
    $0 to $50 copay for Medicare-covered diagnostic procedures and tests
    $10 to $35 copay for Medicare-covered X-rays
    $10 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $35 copay for Medicare-covered therapeutic radiology services
    ** Additional Benefits **
    Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    Transportation
    This plan does not cover supplemental routine transportation.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - MyOption Enhanced Dental HMO:
    $21 monthly premium in addition to your $20 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Preventive Dental
  • Comprehensive Dental
    • ** Important Information **
    Package: 1 - MyOption Enhanced Dental HMO:
    $21 monthly premium in addition to your $20 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Preventive Dental
  • Comprehensive Dental
    • ** Preventive Services **
    Dental Services
    Plan offers additional comprehensive dental benefits.
    $0 copay for the following preventive dental benefits:
  • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • $1 500 plan coverage limit for comprehensive dental benefits every year




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    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
    • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
    • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
    • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
    • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
    • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
    • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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