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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Secure Blue Idaho (PPO)

2015 Medicare Advantage Plan Details
Plan Name:Secure Blue Idaho (PPO)
Location (County, State ZIP):Shoshone, Idaho
Plan ID:H1302 - 001     Click to see other plans

Click here for the Secure Blue Idaho (PPO) enrollment options and to have a copy of this chart sent to your email. Enroll in Secure Blue Idaho (PPO)

— Plan Features —
Monthly Premium:$113.00 (See premium details below.)
Annual Rx Deductible:$200
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$3,400
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:3797    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$4.00$7.00$43.00$93.0027%
  — Number of Drugs per Tier:4941538333881551
Plan’s Summary Star Rating: 3.50 out of 5 Stars.
   - Customer Service Rating: Insufficient data to rate this plan.
   - Member Experience Rating: 3 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
$113.00$52.00$61.00$0.00
Monthly Premium with Low-Income Subsidy:100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
$21.30$31.20$41.10$51.10

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$113 per month. In addition you must keep paying your Medicare Part B premium.
$200 per year 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.
Your yearly limit(s) in this plan:
  • $3 400 for services you receive from in-network providers.
  • $4 500 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 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.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $2 960. 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)$4 copay$12 copay
Tier 2 (Non-Preferred Generic)$7 copay$21 copay
Tier 3 (Preferred Brand)$43 copay$129 copay
Tier 4 (Non-Preferred Brand)$93 copay$279 copay
Tier 5 (Specialty Tier)27% of the costNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)Not Offered$12 copay
Tier 2 (Non-Preferred Generic)Not Offered$21 copay
Tier 3 (Preferred Brand)Not Offered$129 copay
Tier 4 (Non-Preferred Brand)Not Offered$279 copay
Tier 5 (Specialty Tier)27% of the costNot Offered
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 but may pay more than you pay at 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 $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 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 $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$113 per month. In addition you must keep paying your Medicare Part B premium.
$200 per year 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.
Your yearly limit(s) in this plan:
  • $3 400 for services you receive from in-network providers.
  • $4 500 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 in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
  • In-network:  $175 copay
  • Out-of-network:  $175 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:  $40 copay
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
Diabetes Supplies and Services
Diabetes monitoring supplies:
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  You pay nothing
Therapeutic shoes or inserts:
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):
  • In-network:  $175 copay
  • Out-of-network:  30% of the cost
Diagnostic tests and procedures:
  • In-network:  $10 copay
  • Out-of-network:  30% of the cost
Lab services:
  • In-network:  $10 copay
  • Out-of-network:  30% of the cost
Outpatient x-rays:
  • In-network:  $20 copay
  • Out-of-network:  30% of the cost
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
Doctor’s Office Visits
Primary care physician visit:
  • In-network:  $15 copay
  • Out-of-network:  $40 copay
Specialist visit:
  • In-network:  $25 copay
  • Out-of-network:  $40 copay
Durable Medical Equipment (wheelchairs, oxygen, etc.)
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
Emergency Care
$65 copay
If you are admitted to the hospital within 3 days 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:  $25 copay
  • Out-of-network:  $40 copay
Hearing Services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  10% of the cost
  • Out-of-network:  $40 copay
Home Health Care
  • In-network:  10% of the cost
  • Out-of-network:  30% of the cost
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:  
    • $175 copay per day for days 1 through 5
    • You pay nothing per day for days 6 through 90
      • Out-of-network:  
        • $200 copay per day for days 1 through 10
        • You pay nothing per day for days 11 through 90
        • Outpatient group therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  30% of the cost
          Outpatient individual therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  30% of the cost
          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):
          • In-network:  $25 copay
          • Out-of-network:  $40 copay
          Occupational therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  $40 copay
          Physical therapy and speech and language therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  $40 copay
          Outpatient Substance Abuse
          Group therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  30% of the cost
          Individual therapy visit:
          • In-network:  $25 copay
          • Out-of-network:  30% of the cost
          Outpatient Surgery
          Ambulatory surgical center:
          • In-network:  $75-175 copay depending on the service
          • Out-of-network:  30% of the cost
          Outpatient hospital:
          • In-network:  $75-175 copay depending on the service
          • Out-of-network:  30% of the cost
          Over-the-Counter Items
          Not Covered
          Prosthetic Devices (braces, artificial limbs, etc.)
          Prosthetic devices:
          • In-network:  10% of the cost
          • Out-of-network:  30% of the cost
          Related medical supplies:
          • In-network:  10% of the cost
          • Out-of-network:  30% of the cost
          Renal Dialysis
          • In-network:  20% of the cost
          • Out-of-network:  30% of the cost
          Transportation
          Not covered
          Urgently Needed Care
          $25 copay
          Vision Services
          Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
          • In-network:  $0-25 copay depending on the service
          • Out-of-network:  $40 copay
          Routine eye exam (for up to 1 every year):
          • In-network:  $25 copay
          • Out-of-network:  $40 copay
          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
          Our plan pays up to $100 every year for eyewear from any provider.
          ** 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:  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.
          ** Inpatient Care **
          Inpatient Hospital Care
          Our plan covers an unlimited number of days for an inpatient hospital stay.
          • In-network:  
            • $175 copay per day for days 1 through 5
            • You pay nothing per day for days 6 through 90
            • You pay nothing per day for days 91 and beyond
              • Out-of-network:  
                • $200 copay per day for days 1 through 10
                • You pay nothing per day for days 11 and beyond
                • 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:  
                      • $40 copay per day for days 1 through 20
                      • $0 copay per day for days 21 through 100
                      • Out-of-network:  
                        • $100 copay per day for days 1 through 12
                        • You pay nothing per day for days 13 through 100
                        • Outpatient Prescription Drugs
                          For Part B drugs such as chemotherapy drugs1:
                          • In-network:  20% of the cost
                          • Out-of-network:  30% of the cost
                          Other Part B drugs1:
                          • In-network:  20% of the cost
                          • Out-of-network:  30% of the cost
                          After you pay your yearly deductible you pay the following until your total yearly drug costs reach $2 960. 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)$4 copay$12 copay
                          Tier 2 (Non-Preferred Generic)$7 copay$21 copay
                          Tier 3 (Preferred Brand)$43 copay$129 copay
                          Tier 4 (Non-Preferred Brand)$93 copay$279 copay
                          Tier 5 (Specialty Tier)27% of the costNot Offered
                          Standard Mail Order Cost-Sharing
                          TierOne-month supplyThree-month supply
                          Tier 1 (Preferred Generic)Not Offered$12 copay
                          Tier 2 (Non-Preferred Generic)Not Offered$21 copay
                          Tier 3 (Preferred Brand)Not Offered$129 copay
                          Tier 4 (Non-Preferred Brand)Not Offered$279 copay
                          Tier 5 (Specialty Tier)27% of the costNot Offered
                          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 but may pay more than you pay at 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 $2 960.

                          After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 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 $4 700 you pay the greater of:
                          • 5% of the cost or
                          • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
                          ** Outpatient Care **
                          Diabetes Supplies and Services
                          Diabetes monitoring supplies:
                          • In-network:  10% of the cost
                          • Out-of-network:  30% of the cost
                          Diabetes self-management training:
                          • In-network:  You pay nothing
                          • Out-of-network:  You pay nothing
                          Therapeutic shoes or inserts:
                          • In-network:  10% of the cost
                          • Out-of-network:  30% 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:  $25 copay
                          • Out-of-network:  $40 copay
                          Hearing Services
                          Exam to diagnose and treat hearing and balance issues:
                          • In-network:  10% of the cost
                          • Out-of-network:  $40 copay
                          ** Outpatient Medical Services and Supplies **
                          Outpatient Substance Abuse
                          Group therapy visit:
                          • In-network:  $25 copay
                          • Out-of-network:  30% of the cost
                          Individual therapy visit:
                          • In-network:  $25 copay
                          • Out-of-network:  30% of the cost
                          Prosthetic Devices (braces, artificial limbs, etc.)
                          Prosthetic devices:
                          • In-network:  10% of the cost
                          • Out-of-network:  30% of the cost
                          Related medical supplies:
                          • In-network:  10% of the cost
                          • Out-of-network:  30% of the cost
                          ** Additional Benefits **
                          Inpatient Mental Health Care
                          For inpatient mental health care see the "Mental Health Care" section.
                          ** Cost **
                          Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
                          Package 1: Healthy Smiles Plus Dental
                          Benefits include:
                          • Preventive Dental
                          • Comprehensive Dental
                          Additional $29.50 per month. You must keep paying your Medicare Part B premium and your $113 monthly plan premium.
                          $50 per year.
                          Our plan pays up to $1000 every year.
                          ** Important Information **
                          Package 1: Healthy Smiles Plus Dental
                          Benefits include:
                          • Preventive Dental
                          • Comprehensive Dental
                          Additional $29.50 per month. You must keep paying your Medicare Part B premium and your $113 monthly plan premium.
                          $50 per year.
                          Our plan pays up to $1000 every year.

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