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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Martin's Point Generations Advantage Select (PPO)

2015 Medicare Advantage Plan Details
Plan Name:Martin's Point Generations Advantage Select (PPO)
Location (County, State ZIP):Penobscot, Maine
Plan ID:H1365 - 002     Click to see other plans

Click here for the Martin's Point Generations Advantage Select (PPO) enrollment options and to have a copy of this chart sent to your email. Enroll in Martin's Point Generations Advantage Select (PPO)

— Plan Features —
Monthly Premium:$89.00 (See premium details below.)
Annual Rx Deductible:$0
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:2948    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$0.00$6.00$40.00$90.0033%
  — Number of Drugs per Tier:4491346310434409
Number of Members enrolled in this plan in your County:474 members
Plan’s Summary Star Rating: 4.50 out of 5 Stars.
   - Customer Service Rating: Insufficient data to rate this plan.
   - Member Experience Rating: 4 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
$89.00$48.70$28.60$11.70
Monthly Premium with Low-Income Subsidy:100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
$11.70$18.80$26.00$33.10

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$89 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a 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:
  • $3 400 for services you receive from in-network providers.
  • $5 100 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.
No. There are no limits on how much our plan will pay.
** 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:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
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.
Preferred Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0$0
Tier 2 (Non-Preferred Generic)$6 copay$12 copay$18 copay
Tier 3 (Preferred Brand)$40 copay$80 copay$120 copay
Tier 4 (Non-Preferred Brand)$90 copay$180 copay$270 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
Tier 2 (Non-Preferred Generic)$10 copay$20 copay$30 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$10 copay
Tier 2 (Non-Preferred Generic)$10 copay$20 copay$25 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$112.50 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$237.50 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% 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 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
$89 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a 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:
  • $3 400 for services you receive from in-network providers.
  • $5 100 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.
No. There are no limits on how much our plan will pay.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
  • In-network:  $200 copay
  • Out-of-network:  $200 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:  30% of the cost
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $40 copay
  • Out-of-network:  30% of the cost
Diabetes Supplies and Services
Diabetes monitoring supplies:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  You pay nothing
Therapeutic shoes or inserts:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Diagnostic tests and procedures:
  • In-network:  $0-75 copay depending on the service
  • Out-of-network:  $0-75 copay depending on the service
Lab services:
  • In-network:  0-20% of the cost depending on the service
  • Out-of-network:  0-20% of the cost depending on the service
Outpatient x-rays:
  • In-network:  $15 copay
  • Out-of-network:  $15-25 copay depending on the service
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Doctor’s Office Visits
Primary care physician visit:
  • In-network:  $0-20 copay depending on the service
  • Out-of-network:  $15-25 copay depending on the service
Specialist visit:
  • In-network:  $40 copay
  • Out-of-network:  30% of the cost
Durable Medical Equipment (wheelchairs, oxygen, etc.)
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Emergency Care
$65 copay
If you are admitted to the hospital within 24 hours 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:  $40 copay
  • Out-of-network:  30% of the cost
Hearing Services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  $40 copay
  • Out-of-network:  30% of the cost
Home Health Care
  • In-network:  You pay nothing
  • Out-of-network:  20% 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:  
    • $250 copay per day for days 1 through 7
    • You pay nothing per day for days 8 through 90
      • Out-of-network:  
        • 30% of the cost per day for days 1 through 90
        • Outpatient group therapy visit:
          • In-network:  $15 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:  You pay nothing
          • Out-of-network:  30% of the cost
          Occupational therapy visit:
          • In-network:  $35 copay
          • Out-of-network:  30% of the cost
          Physical therapy and speech and language therapy visit:
          • In-network:  $35 copay
          • Out-of-network:  30% of the cost
          Outpatient Substance Abuse
          Group therapy visit:
          • In-network:  $15 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:  $175 copay
          • Out-of-network:  30% of the cost
          Outpatient hospital:
          • In-network:  $0-325 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:  20% of the cost
          • Out-of-network:  30% of the cost
          Related medical supplies:
          • In-network:  20% of the cost
          • Out-of-network:  30% of the cost
          Renal Dialysis
          • In-network:  20% of the cost
          • Out-of-network:  20% of the cost
          Transportation
          Not covered
          Urgently Needed Care
          $40 copay
          If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section for other costs.
          Vision Services
          Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
          • In-network:  $0-40 copay depending on the service
          • Out-of-network:  30% of the cost
          Routine eye exam (for up to 1 every year):
          • In-network:  You pay nothing
          • Out-of-network:  30% of the cost
          Eyeglasses or contact lenses after cataract surgery:
          • In-network:  20% of the cost
          • Out-of-network:  30% of the cost
          ** 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:  30% of the cost
          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:  
            • $250 copay per day for days 1 through 7
            • You pay nothing per day for days 8 through 90
            • You pay nothing per day for days 91 and beyond
              • Out-of-network:  
                • 30% of the cost per day for days 1 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:  
                      • $0 copay per day for days 1 through 7
                      • $40 copay per day for days 8 through 20
                      • $125 copay per day for days 21 through 100
                      • Out-of-network:  
                        • 30% of the cost per day for days 1 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
                          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.
                          Preferred Retail Cost-Sharing
                          TierOne-month supplyTwo-month supplyThree-month supply
                          Tier 1 (Preferred Generic)$0$0$0
                          Tier 2 (Non-Preferred Generic)$6 copay$12 copay$18 copay
                          Tier 3 (Preferred Brand)$40 copay$80 copay$120 copay
                          Tier 4 (Non-Preferred Brand)$90 copay$180 copay$270 copay
                          Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
                          Standard Retail Cost-Sharing
                          TierOne-month supplyTwo-month supplyThree-month supply
                          Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
                          Tier 2 (Non-Preferred Generic)$10 copay$20 copay$30 copay
                          Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
                          Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
                          Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
                          Standard Mail Order Cost-Sharing
                          TierOne-month supplyTwo-month supplyThree-month supply
                          Tier 1 (Preferred Generic)$4 copay$8 copay$10 copay
                          Tier 2 (Non-Preferred Generic)$10 copay$20 copay$25 copay
                          Tier 3 (Preferred Brand)$45 copay$90 copay$112.50 copay
                          Tier 4 (Non-Preferred Brand)$95 copay$190 copay$237.50 copay
                          Tier 5 (Specialty Tier)33% of the cost33% of the cost33% 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 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:  You pay nothing
                          • Out-of-network:  20% of the cost
                          Diabetes self-management training:
                          • In-network:  You pay nothing
                          • Out-of-network:  You pay nothing
                          Therapeutic shoes or inserts:
                          • In-network:  You pay nothing
                          • 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:  $40 copay
                          • Out-of-network:  30% of the cost
                          Hearing Services
                          Exam to diagnose and treat hearing and balance issues:
                          • In-network:  $40 copay
                          • Out-of-network:  30% of the cost
                          ** Outpatient Medical Services and Supplies **
                          Outpatient Substance Abuse
                          Group therapy visit:
                          • In-network:  $15 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:  20% of the cost
                          • Out-of-network:  30% of the cost
                          Related medical supplies:
                          • In-network:  20% 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.

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