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2016 Medicare Advantage Plan Benefit Details for the Health Alliance Medicare PPO Basic Rx (PPO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:Health Alliance Medicare PPO Basic Rx (PPO)
Location:Schuyler, Illinois     Click to see other locations
Plan ID:H1417 - 010 - 0     Click to see other plans
Member Services:1-800-965-4022 TTY users 1-800-526-0844
— 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 Health Alliance Medicare PPO Basic Rx (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$39.00 (see Plan Premium Details below)
Annual Deductible:$360
Annual Initial Coverage Limit (ICL):$3,310
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,800
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,789 drugsBrowse the Health Alliance Medicare PPO Basic Rx (PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$20.00$47.00$100.0025%
• Number of Drugs per
  Tier:		11941096393619487
Plan's Pharmacy Search:http://www.healthalliancemedicare.org
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Schuyler, Illinois:less than 10 members
Number of Members enrolled in this plan in Illinois:1,405 members
Number of Members enrolled in this plan in (H1417 - 010):1,542 members
Plan’s Summary Star Rating: 4 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
$39.00$6.00$33.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$3.40$10.80$18.20$25.60
Total Monthly Premium with LIS (Parts C & D):$9.40$16.80$24.20$31.60
— Plan Health Benefits —
** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$39 per month. In addition you must keep paying your Medicare Part B premium.
$360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 800 for services you receive from in-network providers.
  • $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$16 copay$48 copay
Tier 2 (Generic)$20 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$100 copay$300 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Preferred Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0
Tier 2 (Generic)$20 copay$40 copay
Tier 3 (Preferred Brand)$47 copay$94 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$16 copay$48 copay
Tier 2 (Generic)$20 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$100 copay$300 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
  • 5% of the cost or
  • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$39 per month. In addition you must keep paying your Medicare Part B premium.
$360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 800 for services you receive from in-network providers.
  • $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  $100 copay
  • Out-of-network:  $100 copay
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  $20 copay
  • Out-of-network:  $50 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $25 copay
  • Out-of-network:  $50 copay
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Dental x-ray(s):
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Fluoride treatment:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Oral exam:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Diabetes supplies and services
    Diabetes monitoring supplies:
    • In-network:  0-20% of the cost depending on the supply
    • Out-of-network:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  $50 copay
    Therapeutic shoes or inserts:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans):
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Diagnostic tests and procedures:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Lab services:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Outpatient x-rays:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Doctor's office visits
    Primary care physician visit:
    • In-network:  $20 copay
    • Out-of-network:  $50 copay
    Specialist visit:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Durable medical equipment (wheelchairs, oxygen, etc.)
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Emergency care
    $75 copay
    If you are immediately admitted to the hospital you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Hearing services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Routine hearing exam:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Hearing aid fitting/evaluation:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Hearing aid:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Home health care
    • In-network:  You pay nothing
    • Out-of-network:  $50 copay
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • In-network:  
      • $350 copay per day for days 1 through 4
      • You pay nothing per day for days 5 through 90
        • Out-of-network:  
          • $400 copay per day for days 1 through 4
            • Outpatient group therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  $50 copay
            Outpatient individual therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  $50 copay
            Outpatient rehabilitation
            Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
            • In-network:  You pay nothing
            • Out-of-network:  $50 copay
            Occupational therapy visit:
            • In-network:  $20 copay
            • Out-of-network:  $50 copay
            Physical therapy and speech and language therapy visit:
            • In-network:  $20 copay
            • Out-of-network:  $50 copay
            Outpatient substance abuse
            Group therapy visit:
            • In-network:  $50 copay
            • Out-of-network:  $50 copay
            Individual therapy visit:
            • In-network:  $50 copay
            • Out-of-network:  $50 copay
            Outpatient surgery
            Ambulatory surgical center:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Outpatient hospital:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Over-the-counter items
            Not Covered
            Prosthetic devices (braces, artificial limbs, etc.)
            Prosthetic devices:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Related medical supplies:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Renal dialysis
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Transportation
            Not covered
            Urgently needed services
            $65 copay
            Vision services
            Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
            • In-network:  $25 copay
            • Out-of-network:  $50 copay
            Routine eye exam:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Contact lenses:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglasses (frames and lenses):
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglass frames:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglass lenses:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglasses or contact lenses after cataract surgery:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            ** Hospice **
            Hospice
            You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
            ** Preventive Care **
            Preventive care
            • In-network:  You pay nothing
            • Out-of-network:  $50 copay
            Our plan covers many preventive services including:
            • Abdominal aortic aneurysm screening
            • Alcohol misuse counseling
            • Bone mass measurement
            • Breast cancer screening (mammogram)
            • Cardiovascular disease (behavioral therapy)
            • Cardiovascular screenings
            • Cervical and vaginal cancer screening
            • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
            • Depression screening
            • Diabetes screenings
            • HIV screening
            • Medical nutrition therapy services
            • Obesity screening and counseling
            • Prostate cancer screenings (PSA)
            • Sexually transmitted infections screening and counseling
            • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
            • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
            • "Welcome to Medicare" preventive visit (one-time)
            • Yearly "Wellness" visit
            Any additional preventive services approved by Medicare during the contract year will be covered.
            ** Inpatient Care **
            Inpatient hospital care
            Our plan covers an unlimited number of days for an inpatient hospital stay.
            • In-network:  
              • $390 copay per day for days 1 through 4
              • You pay nothing per day for days 5 through 90
              • You pay nothing per day for days 91 and beyond
                • Out-of-network:  
                  • $450 copay per day for days 1 through 4
                    • Inpatient mental health care
                    For inpatient mental health care see the "Mental Health Care" section.
                    Skilled Nursing Facility (SNF)
                    Our plan covers up to 100 days in a SNF.
                    • In-network:  
                      • You pay nothing per day for days 1 through 20
                      • $150 copay per day for days 21 through 100
                        • Out-of-network:  
                          • $100 copay per day for days 1 through 20
                          • $200 copay per day for days 21 through 100
                            • Outpatient prescription drugs
                            For Part B drugs such as chemotherapy drugs1:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Other Part B drugs1:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
                            You may get your drugs at network retail pharmacies and mail order pharmacies.
                            Standard Retail Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$16 copay$48 copay
                            Tier 2 (Generic)$20 copay$60 copay
                            Tier 3 (Preferred Brand)$47 copay$141 copay
                            Tier 4 (Non-Preferred Brand)$100 copay$300 copay
                            Tier 5 (Specialty Tier)25% of the cost25% of the cost
                            Preferred Retail Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$0$0
                            Tier 2 (Generic)$20 copay$40 copay
                            Tier 3 (Preferred Brand)$47 copay$94 copay
                            Tier 4 (Non-Preferred Brand)$100 copay$200 copay
                            Tier 5 (Specialty Tier)25% of the cost25% of the cost
                            Standard Mail Order Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$16 copay$48 copay
                            Tier 2 (Generic)$20 copay$60 copay
                            Tier 3 (Preferred Brand)$47 copay$141 copay
                            Tier 4 (Non-Preferred Brand)$100 copay$300 copay
                            Tier 5 (Specialty Tier)25% of the cost25% of the cost
                            If you reside in a long-term care facility you pay the same as at a retail pharmacy.
                            You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
                            Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

                            After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

                            After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
                            • 5% of the cost or
                            • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
                            ** Outpatient Care **
                            Diabetes supplies and services
                            Diabetes monitoring supplies:
                            • In-network:  0-20% of the cost depending on the supply
                            • Out-of-network:  20% of the cost
                            Diabetes self-management training:
                            • In-network:  You pay nothing
                            • Out-of-network:  $50 copay
                            Therapeutic shoes or inserts:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Foot care (podiatry services)
                            Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Hearing services
                            Exam to diagnose and treat hearing and balance issues:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Routine hearing exam:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            Hearing aid fitting/evaluation:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            Hearing aid:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            ** Outpatient Medical Services and Supplies **
                            Outpatient substance abuse
                            Group therapy visit:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Individual therapy visit:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Prosthetic devices (braces, artificial limbs, etc.)
                            Prosthetic devices:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Related medical supplies:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            ** Additional Benefits **
                            Inpatient mental health care
                            For inpatient mental health care see the "Mental Health Care" section.




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                            • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
                            • Limitations, copayments, and restrictions may apply.
                            • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
                              Statement required by Medicare:
                              "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
                            • 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.
                            .