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2015 Medicare Advantage Plan Benefits in Plain Text

Description of the HAP Midwest Health Plan (HMO SNP) plan (H5685 - 001) in Wayne, Michigan



Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the HAP Midwest Health Plan (HMO SNP) plan (H5685 - 001) in Wayne, Michigan only.   To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see this information for the HAP Midwest Health Plan (HMO SNP) plan in a chart format along with the plan enrollment options. We will also send a copy of the plan benefit details chart to your email account.

Plan Premium
The HAP Midwest Health Plan (HMO SNP) plan has a monthly premium of $31.50. That is $378.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $31.50 montly premium is in addition to your Medicare Part B premium.

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings
The HAP Midwest Health Plan (HMO SNP) plan currently has 1,354 members in Wayne county. The Centers for Medicare and Medicaid Services (CMS) has has given this plan carrier a summary rating of -1.00 stars. The detail CMS plan carrier ratings are as follows: , a Member Experience Rating of -1 out of 5 stars, and a Drug Cost Information Accuracy Rating of -1 out of 5 stars.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (See cost-sharing below). The maximum deductible for 2015 is $320. This plan (HAP Midwest Health Plan (HMO SNP)) has no deductible.
The following information is about the HAP Midwest Health Plan (HMO SNP) formulary (or drug list). There are 2970 drugs on the HAP Midwest Health Plan (HMO SNP) formulary. Click here to browse the HAP Midwest Health Plan (HMO SNP) Formulary.
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The HAP Midwest Health Plan (HMO SNP) plan’s formulary is divided into 2 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
Tier 1 contains Generic drugs. The tier 1 co-payment is $0.00.
Tier 2 contains Brand drugs. The tier 2 co-payment is $0.00.     

Click here to browse the HAP Midwest Health Plan (HMO SNP) Formulary.
The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 35% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 55% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (HAP Midwest Health Plan (HMO SNP)) offers No Coverage during the Coverage Gap phase.
The HAP Midwest Health Plan (HMO SNP) plan offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.
Cost - Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$0 per month.
This plan does not have a deductible.
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).
This plan does not have a deductible for Part D prescription drugs.
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.
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
Your yearly limit(s) in this plan:
  • $6 700 for services you receive from in-network providers.
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 in-network benefits. Contact us for the services that apply.
Doctor and Hospital Choice - Acupuncture and Other Alternative Therapies
Not covered
Extra Benefits - Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Extra Benefits - Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  You pay nothing
Other Part B drugs1:  You pay nothing
Our plan does not have a deductible for Part D prescription drugs.
You pay the following:
You may get your drugs at network retail pharmacies.
Standard Retail Cost-Sharing
TierOne-month supply
Tier 1 (Generic)$0
Tier 2 (Brand)$0
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 and pay the same as an in-network pharmacy but you will get less of the drug.
You pay nothing
Important Information - Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$0 per month.
This plan does not have a deductible.
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).
This plan does not have a deductible for Part D prescription drugs.
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.
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
Your yearly limit(s) in this plan:
  • $6 700 for services you receive from in-network providers.
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 in-network benefits. Contact us for the services that apply.
Outpatient Care and Services - Acupuncture and Other Alternative Therapies
Not covered
Outpatient Care and Services - Ambulance Services
You pay nothing
Outpatient Care and Services - Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  You pay nothing
Outpatient Care and Services - Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  You pay nothing
Preventive dental services:
  • Cleaning (for up to 1 every year):  You pay nothing
  • Dental x-ray(s) (for up to 1 every year):  You pay nothing
  • Fluoride treatment (for up to 1 every year):  You pay nothing
  • Oral exam:  You pay nothing
  • Our plan pays up to $1 000 every year for most dental services.
    Outpatient Care and Services - Diabetes Supplies and Services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Outpatient Care and Services - Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):  You pay nothing
    Diagnostic tests and procedures:  You pay nothing
    Lab services:  You pay nothing
    Outpatient x-rays:  You pay nothing
    Therapeutic radiology services (such as radiation treatment for cancer):  You pay nothing
    Outpatient Care and Services - Doctor’s Office Visits
    Primary care physician visit:  You pay nothing
    Specialist visit:  You pay nothing
    Outpatient Care and Services - Durable Medical Equipment (wheelchairs, oxygen, etc.)
    You pay nothing
    Outpatient Care and Services - Emergency Care
    You pay nothing
    Outpatient Care and Services - Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
    Routine foot care (for up to 6 visit(s) every year):  You pay nothing
    Outpatient Care and Services - Hearing Services
    Exam to diagnose and treat hearing and balance issues:  You pay nothing
    Routine hearing exam (for up to 1 every year):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $2 500 every year for hearing aids.
    Outpatient Care and Services - Home Health Care
    You pay nothing
    Outpatient Care and Services - 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.
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    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.
    You pay nothing
    Outpatient group therapy visit:  You pay nothing
    Outpatient individual therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Rehabilitation Services
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  You pay nothing
    Occupational therapy visit:  You pay nothing
    Physical therapy and speech and language therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Substance Abuse
    Group therapy visit:  You pay nothing
    Individual therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Surgery
    Ambulatory surgical center:  You pay nothing
    Outpatient hospital:  You pay nothing
    Outpatient Care and Services - Over-the-Counter Items
    Please visit our website to see our list of covered over-the-counter items.
    Outpatient Care and Services - Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  You pay nothing
    Related medical supplies:  You pay nothing
    Outpatient Care and Services - Renal Dialysis
    You pay nothing
    Outpatient Care and Services - Transportation
      You pay nothing
    Outpatient Care and Services - Urgently Needed Care
    You pay nothing
    Outpatient Care and Services - Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  You pay nothing
    Routine eye exam (for up to 1 every two years):  You pay nothing
    Eyeglasses (frames and lenses) (for up to 1 every two years):  You pay nothing
    Our plan pays up to $125 every two years for eyeglasses (frames and lenses).
    Eyeglasses or contact lenses after cataract surgery:  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
    You pay nothing
    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
    • Colonoscopy
    • Colorectal cancer screenings
    • Depression screening
    • Diabetes screenings
    • Fecal occult blood test
    • Flexible sigmoidoscopy
    • 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.
    Annual physical exam:  You pay nothing
    Inpatient Care - Inpatient Hospital Care
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    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.
    You pay nothing
    Inpatient Care - Inpatient Mental Health Care
    For inpatient mental health care see the "Mental Health Care" section.
    Inpatient Care - Skilled Nursing Facility (SNF)
    Our plan covers up to 100 days in a SNF.
    You pay nothing
    Inpatient Care - Outpatient Prescription Drugs
    For Part B drugs such as chemotherapy drugs1:  You pay nothing
    Other Part B drugs1:  You pay nothing
    Our plan does not have a deductible for Part D prescription drugs.
    You pay the following:
    You may get your drugs at network retail pharmacies.
    Standard Retail Cost-Sharing
    TierOne-month supply
    Tier 1 (Generic)$0
    Tier 2 (Brand)$0
    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 and pay the same as an in-network pharmacy but you will get less of the drug.
    You pay nothing
    Outpatient Care - Diabetes Supplies and Services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Outpatient Care - Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
    Routine foot care (for up to 6 visit(s) every year):  You pay nothing
    Outpatient Care - Hearing Services
    Exam to diagnose and treat hearing and balance issues:  You pay nothing
    Routine hearing exam (for up to 1 every year):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $2 500 every year for hearing aids.
    Outpatient Medical Services and Supplies - Outpatient Substance Abuse
    Group therapy visit:  You pay nothing
    Individual therapy visit:  You pay nothing
    Outpatient Medical Services and Supplies - Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  You pay nothing
    Related medical supplies:  You pay nothing
    Additional Benefits - Inpatient Mental Health Care
    For inpatient mental health care see the "Mental Health Care" section.

    Description of the HAP Midwest Health Plan (HMO SNP) plan (H5685 - 001) in Wayne, Michigan



    Medicare Advantage Plan Benefit Details in Plain Text
    The following Medicare Advantage plan benefits apply to the HAP Midwest Health Plan (HMO SNP) plan (H5685 - 001) in Wayne, Michigan only.   To switch to a different Medicare Advantage plan or to change your location, click here.
    Click here to see this information for the HAP Midwest Health Plan (HMO SNP) plan in a chart format along with the plan enrollment options. We will also send a copy of the plan benefit details chart to your email account.

    Plan Premium
    The HAP Midwest Health Plan (HMO SNP) plan has a monthly premium of $31.50. That is $378.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $31.50 montly premium is in addition to your Medicare Part B premium.

    This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

    Plan Membership and Plan Ratings
    The HAP Midwest Health Plan (HMO SNP) plan currently has 1,354 members in Wayne county. The Centers for Medicare and Medicaid Services (CMS) has has given this plan carrier a summary rating of -1.00 stars. The detail CMS plan carrier ratings are as follows: , a Member Experience Rating of -1 out of 5 stars, and a Drug Cost Information Accuracy Rating of -1 out of 5 stars.

    Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
    This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (See cost-sharing below). The maximum deductible for 2015 is $320. This plan (HAP Midwest Health Plan (HMO SNP)) has no deductible.
    The following information is about the HAP Midwest Health Plan (HMO SNP) formulary (or drug list). There are 2970 drugs on the HAP Midwest Health Plan (HMO SNP) formulary. Click here to browse the HAP Midwest Health Plan (HMO SNP) Formulary.
    The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The HAP Midwest Health Plan (HMO SNP) plan’s formulary is divided into 2 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
    Tier 1 contains Generic drugs. The tier 1 co-payment is $0.00.
    Tier 2 contains Brand drugs. The tier 2 co-payment is $0.00.     

    Click here to browse the HAP Midwest Health Plan (HMO SNP) Formulary.
    The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 35% of your generic drug prescription costs in the donut hole on your behalf.

    The brand-name drug manufacturer will pay 50% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 55% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (HAP Midwest Health Plan (HMO SNP)) offers No Coverage during the Coverage Gap phase.
    The HAP Midwest Health Plan (HMO SNP) plan offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.
    Cost - Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
    $0 per month.
    This plan does not have a deductible.
    This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).
    This plan does not have a deductible for Part D prescription drugs.
    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.
    In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
    Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
    Your yearly limit(s) in this plan:
    • $6 700 for services you receive from in-network providers.
    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 in-network benefits. Contact us for the services that apply.
    Doctor and Hospital Choice - Acupuncture and Other Alternative Therapies
    Not covered
    Extra Benefits - Inpatient Mental Health Care
    For inpatient mental health care see the "Mental Health Care" section.
    Extra Benefits - Outpatient Prescription Drugs
    For Part B drugs such as chemotherapy drugs1:  You pay nothing
    Other Part B drugs1:  You pay nothing
    Our plan does not have a deductible for Part D prescription drugs.
    You pay the following:
    You may get your drugs at network retail pharmacies.
    Standard Retail Cost-Sharing
    TierOne-month supply
    Tier 1 (Generic)$0
    Tier 2 (Brand)$0
    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 and pay the same as an in-network pharmacy but you will get less of the drug.
    You pay nothing
    Important Information - Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
    $0 per month.
    This plan does not have a deductible.
    This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).
    This plan does not have a deductible for Part D prescription drugs.
    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.
    In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
    Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
    Your yearly limit(s) in this plan:
    • $6 700 for services you receive from in-network providers.
    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 in-network benefits. Contact us for the services that apply.
    Outpatient Care and Services - Acupuncture and Other Alternative Therapies
    Not covered
    Outpatient Care and Services - Ambulance Services
    You pay nothing
    Outpatient Care and Services - Chiropractic Care
    Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  You pay nothing
    Outpatient Care and Services - Dental Services
    Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  You pay nothing
    Preventive dental services:
  • Cleaning (for up to 1 every year):  You pay nothing
  • Dental x-ray(s) (for up to 1 every year):  You pay nothing
  • Fluoride treatment (for up to 1 every year):  You pay nothing
  • Oral exam:  You pay nothing
  • Our plan pays up to $1 000 every year for most dental services.
    Outpatient Care and Services - Diabetes Supplies and Services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Outpatient Care and Services - Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):  You pay nothing
    Diagnostic tests and procedures:  You pay nothing
    Lab services:  You pay nothing
    Outpatient x-rays:  You pay nothing
    Therapeutic radiology services (such as radiation treatment for cancer):  You pay nothing
    Outpatient Care and Services - Doctor’s Office Visits
    Primary care physician visit:  You pay nothing
    Specialist visit:  You pay nothing
    Outpatient Care and Services - Durable Medical Equipment (wheelchairs, oxygen, etc.)
    You pay nothing
    Outpatient Care and Services - Emergency Care
    You pay nothing
    Outpatient Care and Services - Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
    Routine foot care (for up to 6 visit(s) every year):  You pay nothing
    Outpatient Care and Services - Hearing Services
    Exam to diagnose and treat hearing and balance issues:  You pay nothing
    Routine hearing exam (for up to 1 every year):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $2 500 every year for hearing aids.
    Outpatient Care and Services - Home Health Care
    You pay nothing
    Outpatient Care and Services - 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.
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    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.
    You pay nothing
    Outpatient group therapy visit:  You pay nothing
    Outpatient individual therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Rehabilitation Services
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  You pay nothing
    Occupational therapy visit:  You pay nothing
    Physical therapy and speech and language therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Substance Abuse
    Group therapy visit:  You pay nothing
    Individual therapy visit:  You pay nothing
    Outpatient Care and Services - Outpatient Surgery
    Ambulatory surgical center:  You pay nothing
    Outpatient hospital:  You pay nothing
    Outpatient Care and Services - Over-the-Counter Items
    Please visit our website to see our list of covered over-the-counter items.
    Outpatient Care and Services - Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  You pay nothing
    Related medical supplies:  You pay nothing
    Outpatient Care and Services - Renal Dialysis
    You pay nothing
    Outpatient Care and Services - Transportation
      You pay nothing
    Outpatient Care and Services - Urgently Needed Care
    You pay nothing
    Outpatient Care and Services - Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  You pay nothing
    Routine eye exam (for up to 1 every two years):  You pay nothing
    Eyeglasses (frames and lenses) (for up to 1 every two years):  You pay nothing
    Our plan pays up to $125 every two years for eyeglasses (frames and lenses).
    Eyeglasses or contact lenses after cataract surgery:  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
    You pay nothing
    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
    • Colonoscopy
    • Colorectal cancer screenings
    • Depression screening
    • Diabetes screenings
    • Fecal occult blood test
    • Flexible sigmoidoscopy
    • 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.
    Annual physical exam:  You pay nothing
    Inpatient Care - Inpatient Hospital Care
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    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.
    You pay nothing
    Inpatient Care - Inpatient Mental Health Care
    For inpatient mental health care see the "Mental Health Care" section.
    Inpatient Care - Skilled Nursing Facility (SNF)
    Our plan covers up to 100 days in a SNF.
    You pay nothing
    Inpatient Care - Outpatient Prescription Drugs
    For Part B drugs such as chemotherapy drugs1:  You pay nothing
    Other Part B drugs1:  You pay nothing
    Our plan does not have a deductible for Part D prescription drugs.
    You pay the following:
    You may get your drugs at network retail pharmacies.
    Standard Retail Cost-Sharing
    TierOne-month supply
    Tier 1 (Generic)$0
    Tier 2 (Brand)$0
    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 and pay the same as an in-network pharmacy but you will get less of the drug.
    You pay nothing
    Outpatient Care - Diabetes Supplies and Services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Outpatient Care - Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
    Routine foot care (for up to 6 visit(s) every year):  You pay nothing
    Outpatient Care - Hearing Services
    Exam to diagnose and treat hearing and balance issues:  You pay nothing
    Routine hearing exam (for up to 1 every year):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $2 500 every year for hearing aids.
    Outpatient Medical Services and Supplies - Outpatient Substance Abuse
    Group therapy visit:  You pay nothing
    Individual therapy visit:  You pay nothing
    Outpatient Medical Services and Supplies - Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  You pay nothing
    Related medical supplies:  You pay nothing
    Additional Benefits - Inpatient Mental Health Care
    For inpatient mental health care see the "Mental Health Care" section.
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    • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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    • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
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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.
    • 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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