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2013 Medicare Advantage Plan Benefit Details for the Medica Prime Solution Value with Part D Option 2 (Cost)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2013 Medicare Advantage Plan Details
Medicare Plan Name:Medica Prime Solution Value with Part D Option 2 (Cost)
Location:Polk, Wisconsin     Click to see other locations
Plan ID:H2450 - 023 - 0     Click to see other plans
Member Services:1-800-234-8755 TTY users 1-800-855-2880
— 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 Medica Prime Solution Value with Part D Option 2 (Cost) benefit details
— Medicare Plan Features —
Monthly Premium:$111.90 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,970
Health Plan Type:Cost
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,350
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:5,138 drugsBrowse the Medica Prime Solution Value with Part D Option 2 (Cost) 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:		$10.00$34.00$74.0025% 
• Number of Drugs per
  Tier:		21415432003474
Plan's Pharmacy Search:http://www.medica.com/C12/DrugFormularyPartD/default.aspx
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in (H2450 - 023):2,888 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 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
$111.9 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 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.
$3 350 out-of-pocket limit. All plan services included.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance.
Plan covers you when you travel in the U.S. or its territories.
** Extra Benefits **
Over-the-Counter Items
The plan does not cover Over-the-Counter items.
Transportation
This plan does not cover supplemental routine transportation.
** Important Information **
Premium and Other Important Information
$111.9 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 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.
$3 350 out-of-pocket limit. All plan services included.
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance.
Plan covers you when you travel in the U.S. or its territories.
** Inpatient Care **
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
$300 copay for each Medicare-covered hospital stay
$0 copay for additional hospital days
Inpatient Mental Health Care
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.
$300 copay for each Medicare-covered hospital stay.
$0 copay for additional hospital days
Skilled Nursing Facility (SNF)
Plan covers up to 100 days each benefit period
For Medicare-covered SNF stays:
  • Days 1 - 20: $0 copay per day
  • Days 21 - 100: $80 copay per day
    • Home Health Care
    $0 copay for Medicare-covered home health visits
    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
    $10 copay for each Medicare-covered primary care doctor visit.
    $30 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    $20 copay for each Medicare-covered chiropractic visit
    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.
    Podiatry Services
    $30 copay for each Medicare-covered podiatry visit
    Medicare-covered podiatry visits are for medically-necessary foot care.
    Outpatient Mental Health Care
    $30 copay for each Medicare-covered individual therapy visit
    $30 copay for each Medicare-covered group therapy visit
    $30 copay for each Medicare-covered individual therapy visit with a psychiatrist
    $30 copay for each Medicare-covered group therapy visit with a psychiatrist
    $30 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    $30 copay for Medicare-covered individual substance abuse outpatient treatment visits
    $30 copay for Medicare-covered group substance abuse outpatient treatment visits
    Outpatient Services
    $125 copay for each Medicare-covered ambulatory surgical center visit
    $125 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    $50 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits
    $20 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.
    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 $30 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits.
    $30 copay for Medicare-covered Occupational Therapy visits
    $30 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered durable medical equipment
    Prosthetic Devices
    20% of the cost for Medicare-covered prosthetic devices
    Diabetes Programs and Supplies
    $0 copay for Medicare-covered Diabetes self-management training
    20% of the cost for Medicare-covered Diabetes monitoring supplies
    20% of the cost for Medicare-covered Therapeutic shoes or inserts
    If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $10 to $30 may apply
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    0% of the cost for Medicare-covered lab services
    10% of the cost for Medicare-covered diagnostic procedures and tests
    10% of the cost for Medicare-covered X-rays
    10% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
    10% of the cost for Medicare-covered therapeutic radiology services
    If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 to $30 may apply
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $30 may apply
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    $30 copay for Medicare-covered Cardiac Rehabilitation Services
    $30 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
    $30 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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
    $0 copay for an annual physical exam
    The plan covers the following supplemental education/wellness programs:
    • Additional Smoking and Tobacco Use Cessation Visits
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Kidney Disease and Conditions
    Cost plan members pay Original Medicare cost sharing for out-of-area dialysis.
    $0 copay for Medicare-covered renal dialysis
    $10 to $30 copay for Medicare-covered kidney disease education services
    Outpatient Prescription Drugs
    20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.medica.com/C12/DrugFormularyPartD/default.aspx 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 Medica Prime Solution Value with Part D Option 2 (Cost) 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 Medica Prime Solution Value with Part D Option 2 (Cost) approves the exception you will pay Tier 3: Non-Preferred Brand cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 970:
    Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $10 copay for a one-month (31-day) supply of drugs in this tier
  • $34 copay for a one-month (31-day) supply of drugs in this tier
  • $74 copay for a one-month (31-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (31-day) supply of drugs in this tier
  • $30 copay for a three-month (90-day) supply of drugs in this tier
  • $102 copay for a three-month (90-day) supply of drugs in this tier
  • $222 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $10 copay for a one-month (31-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (31-day) supply of drugs in this tier
  • $34 copay for a one-month (31-day) supply of drugs in this tier
  • $74 copay for a one-month (31-day) supply of drugs in this tier
    • Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.
    Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $20 copay for a three-month (90-day) supply of drugs in this tier
  • $68 copay for a three-month (90-day) supply of drugs in this tier
  • $148 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • After your total yearly drug costs reach $2 970 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 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750.
    After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
    • 5% coinsurance or
    • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 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 Medica Prime Solution Value with Part D Option 2 (Cost).
    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 $2 970:
    Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $10 copay for a one-month (31-day) supply of drugs in this tier
  • $34 copay for a one-month (31-day) supply of drugs in this tier
  • $74 copay for a one-month (31-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (31-day) supply of drugs in this tier
    • You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).
    After your yearly out-of-pocket drug costs reach $4 750 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
    • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
    Dental Services
    This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.")
    20% of the cost for Medicare-covered dental benefits
    Hearing Services
    Hearing aids not covered.
    $30 copay for Medicare-covered diagnostic hearing exams
    $30 copay for up to 1 supplemental routine hearing exam(s) every year
    ** Additional Benefits **
    Vision Services
    • $50 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
  • $30 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.
  • $30 copay for up to 1 supplemental routine eye exam(s) every year
    • Over-the-Counter Items
    The plan does not cover Over-the-Counter items.
    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.
    $300 copay for each Medicare-covered hospital stay
    $0 copay for additional hospital days
    ** Outpatient Care **
    Doctor Office Visits
    $10 copay for each Medicare-covered primary care doctor visit.
    $30 copay for each Medicare-covered specialist visit.
    Outpatient Services
    $125 copay for each Medicare-covered ambulatory surgical center visit
    $125 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    $50 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered durable medical equipment
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    0% of the cost for Medicare-covered lab services
    10% of the cost for Medicare-covered diagnostic procedures and tests
    10% of the cost for Medicare-covered X-rays
    10% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
    10% of the cost for Medicare-covered therapeutic radiology services
    If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 to $30 may apply
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $30 may apply
    ** Additional Benefits **
    Over-the-Counter Items
    The plan does not cover Over-the-Counter items.
    Transportation
    This plan does not cover supplemental routine transportation.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - Medica Senior Dental:
    $48.75 monthly premium in addition to your $111.90 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 000 plan coverage limit every year for these benefits.
    ** Important Information **
    Package: 1 - Medica Senior Dental:
    $48.75 monthly premium in addition to your $111.90 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 000 plan coverage limit every year for these benefits.
    ** Preventive Services **
    Dental Services
    Plan offers additional comprehensive dental benefits.
    • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s)
    • $1 000 plan coverage limit for dental benefits every year




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