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Medicare Advantage Plan Benefit Details in Plain Text |
| The following Medicare Advantage plan benefits apply to the Bravo-HealthSpring Select (HMO SNP) plan (H3949 - 009) in Bucks, Pennsylvania only.
To switch to a different Medicare Advantage plan or to change your location, click here. |
Click here to see this information for the Bravo-HealthSpring Select (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.
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| Plan Premium |
The Bravo-HealthSpring Select (HMO SNP) plan has a monthly premium of $36.60. That is $439.20 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 $36.60 montly premium is in addition to your Medicare Part B premium.
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This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.
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| Plan Membership and Plan Ratings |
The Bravo-HealthSpring Select (HMO SNP) plan currently has 12,173 members in Bucks county. The Centers for Medicare and Medicaid Services (CMS) has has given this plan carrier a summary rating of 3.00 stars. The detail CMS plan carrier ratings are as follows: a Customer Service Rating of 3 out of 5 stars , a Member Experience Rating of 3 out of 5 stars, and a Drug Cost Information Accuracy Rating of 3 out of 5 stars.
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| Prescription Drug Coverage: Deductible, Cost-sharing, Formulary |
| This plan has a $325.00 deductible. That means that you are 100% responsible for the first $325.00 in medication costs and after that is met, the Bravo-HealthSpring Select (HMO SNP) plan will share the costs of your medications with you. (See cost-sharing below). $325.00 is the maximum deductible for 2013. There are other plans with a lower deductible or even a $0 deductible. |
| The following information is about the Bravo-HealthSpring Select (HMO SNP) formulary (or drug list). There are 2860 drugs on the Bravo-HealthSpring Select (HMO SNP) formulary. Click here to browse the Bravo-HealthSpring Select (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. Once you have spent $325.00, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Bravo-HealthSpring Select (HMO SNP) plan’s formulary is divided into 1 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 Tier 1 drugs. The tier 1 co-insurance is 25% of the drug costs. Click here to browse the Bravo-HealthSpring Select (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 21% 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 2.5% of the cost of your brand-name drugs pruchased in the Donut Hole. 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 (Bravo-HealthSpring Select (HMO SNP)) offers No Coverage during the Coverage Gap phase. |
| The Bravo-HealthSpring Select (HMO SNP) plan offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail. |
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| Cost - Premium and Other Important Information |
| * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
| $36.6 monthly plan premium in addition to your monthly Medicare Part B premium.* |
| $6 700 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 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. |
| Extra Benefits - Transportation |
| Authorization rules may apply. |
| $0 copay for up to 36 one-way trip(s) to plan-approved location every year |
| Important Information - Premium and Other Important Information |
| * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
| $36.6 monthly plan premium in addition to your monthly Medicare Part B premium.* |
| $6 700 out-of-pocket limit for Medicare-covered services.* |
| Important Information - Doctor and Hospital Choice |
| You must go to network doctors specialists and hospitals. |
| Referral required for network specialists (for certain benefits). |
| Inpatient Care - Inpatient Hospital Care |
| Plan covers 90 days each benefit period. |
| For Medicare-covered hospital stays $0 or |
- Days 1 - 7: $225 copay per day*
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| 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. |
| Inpatient Care - 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 $0 or |
- Days 1 - 7: $200 copay per day*
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| 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. |
| Inpatient Care - Skilled Nursing Facility (SNF) |
| Authorization rules may apply. |
| Plan covers up to 100 days each benefit period |
| No prior hospital stay is required. |
| For Medicare-covered SNF stays $0 or |
- Days 1 - 10: $0 copay per day*
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| Days 11 - 20: $50 copay per day* |
| Days 21 - 100: $150 copay per day* |
| For SNF stays: |
- Days 1 - 10: $0 copay per day
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| Days 11 - 20: $50 copay per day |
| Days 21 - 100: $150 copay per day |
| Inpatient Care - Home Health Care |
| Authorization rules may apply. |
| $0 copay for Medicare-covered home health visits* |
| Inpatient Care - 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 |
| $0 copay for each Medicare-covered primary care doctor visit.* |
| 0% or 20% of the cost for each Medicare-covered specialist visit.* |
| Outpatient Care - Chiropractic Services |
| 0% or 20% of the cost 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. |
| Outpatient Care - Podiatry Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for each Medicare-covered podiatry visit* |
| Medicare-covered podiatry visits are for medically-necessary foot care. |
| Outpatient Care - Outpatient Mental Health Care |
| Authorization rules may apply. |
| 0% or 20% of the cost for each Medicare-covered individual therapy visit* |
| 0% or 20% of the cost for each Medicare-covered group therapy visit* |
| 0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist* |
| 0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist* |
| 0% or 20% of the cost for Medicare-covered partial hospitalization program services* |
| Outpatient Care - Outpatient Substance Abuse Care |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits* |
| 0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits* |
| Outpatient Care - Outpatient Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
| 0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
| Outpatient Care - Ambulance Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered ambulance benefits.* |
| Outpatient Care - Emergency Care |
| $0 or $65 copay for Medicare-covered emergency room visits* |
| $50 000 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. |
| Outpatient Care - Urgently Needed Care |
| 0% or 20% of the cost for Medicare-covered urgently-needed-care visits* |
| If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. |
| Outpatient Care - Outpatient Rehabilitation Services |
| Authorization rules may apply. |
| There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
| 0% or 20% of the cost for Medicare-covered Occupational Therapy visits* |
| 0% or 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* |
| Outpatient Medical Services and Supplies - Durable Medical Equipment |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered durable medical equipment* |
| Outpatient Medical Services and Supplies - Prosthetic Devices |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered prosthetic devices* |
| Outpatient Medical Services and Supplies - Diabetes Programs and Supplies |
| $0 copay for Medicare-covered Diabetes self-management training* |
| 0% or 0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies* |
| Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies. |
| 0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts* |
| Outpatient Medical Services and Supplies - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
| Authorization rules may apply. |
| $0 copay for Medicare-covered: |
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| diagnostic procedures and tests* |
| 0% or 20% of the cost for Medicare-covered X-rays* |
| 0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
| 0% or 20% 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 0% or 0% to 20% of the cost may apply* |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 0% to 20% of the cost may apply* |
| Preventive Services - Cardiac and Pulmonary Rehabilitation Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services* |
| 0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* |
| 0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services* |
| Preventive 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. |
| The plan covers the following supplemental education/wellness programs: |
- Health Club Membership/Fitness Classes
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| $0 copay for Home Safety Benefit. Contact plan for details. |
| Preventive Services - Kidney Disease and Conditions |
| 0% or 20% of the cost for Medicare-covered renal dialysis* |
| $0 copay for Medicare-covered kidney disease education services* |
| Preventive Services - Outpatient Prescription Drugs |
| $0 yearly deductible for Medicare Part B drugs.* |
| 0% or 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 www.mybravohealth.com 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.
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| 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 you the plan and Medicare. |
| 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 Bravo-HealthSpring Select (HMO SNP) 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. |
| You pay a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
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| You can get drugs the following way(s): |
- one-month (30-day) supply
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| two-month (60-day) supply |
| three-month (90-day) supply |
| Not all drugs are available at this extended day supply. Please contact the plan for more information. |
| You can get drugs the following way(s): |
- one-month (31-day) supply of generic drugs
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| 31-day supply of brand drugs. |
| 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. |
| You can get drugs the following way(s): |
- three-month (90-day) supply
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| Not all drugs are available at this extended day supply. Please contact the plan for more information. |
| After your yearly out-of-pocket drug costs reach $4 750 you pay a $0 copay. |
| 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 Bravo-HealthSpring Select (HMO SNP). |
| You can get out-of-network drugs the following way: |
- one-month (30-day) supply
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Depending on your income and institutional status you will be reimbursed by Bravo-HealthSpring Select (HMO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: A $0 copay or A $1.15 copay or A $2.65 copay For all other drugs purchased out-of-network either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
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| After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network. |
| Preventive Services - Dental Services |
| Authorization rules may apply. |
| $0 copay for Medicare-covered dental benefits* |
| $0 copay for the following preventive dental benefits: |
- up to 1 oral exam(s) every year
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| up to 1 cleaning(s) every six months |
| up to 1 fluoride treatment(s) every year |
| up to 1 dental x-ray(s) every year |
| Plan offers additional comprehensive dental benefits. |
| $800 plan coverage limit for comprehensive dental benefits every year |
| Preventive Services - Hearing Services |
| $0 copay for: |
- up to 1 supplemental routine hearing exam(s) every year
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| up to 1 fitting-evaluation(s) for a hearing aid every year |
| $0 copay for hearing aids. |
| 0% or 20% of the cost for Medicare-covered diagnostic hearing exams* |
| $1 400 plan coverage limit for hearing aids every three years. |
| Additional Benefits - Vision Services |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
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- up to 1 pair(s) of glasses every two years
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| up to 1 pair(s) of contacts every two years |
| 0% or 0% to 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.* |
| $0 copay for up to 1 supplemental routine eye exam(s) every year |
| $100 plan coverage limit for eye wear every two years. |
| 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. |
| Additional Benefits - Transportation |
| Authorization rules may apply. |
| $0 copay for up to 36 one-way trip(s) to plan-approved location every year |
| Additional Benefits - Acupuncture |
| This plan does not cover Acupuncture. |
| Inpatient Care - Inpatient Hospital Care |
| Plan covers 90 days each benefit period. |
| For Medicare-covered hospital stays $0 or |
- Days 1 - 7: $225 copay per day*
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| 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. |
| Outpatient Care - Doctor Office Visits |
| $0 copay for each Medicare-covered primary care doctor visit.* |
| 0% or 20% of the cost for each Medicare-covered specialist visit.* |
| Outpatient Care - Outpatient Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
| 0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
| Outpatient Care - Ambulance Services |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered ambulance benefits.* |
| Outpatient Medical Services and Supplies - Durable Medical Equipment |
| Authorization rules may apply. |
| 0% or 20% of the cost for Medicare-covered durable medical equipment* |
| Outpatient Medical Services and Supplies - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
| Authorization rules may apply. |
| $0 copay for Medicare-covered: |
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| diagnostic procedures and tests* |
| 0% or 20% of the cost for Medicare-covered X-rays* |
| 0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
| 0% or 20% 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 0% or 0% to 20% of the cost may apply* |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 0% to 20% of the cost may apply* |
| 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. |
| Additional Benefits - Transportation |
| Authorization rules may apply. |
| $0 copay for up to 36 one-way trip(s) to plan-approved location every year |
