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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Independent Health Encompass 65 Basic (HMO-POS)

2015 Medicare Advantage Plan Details
Plan Name:Independent Health Encompass 65 Basic (HMO-POS)
Location (County, State ZIP):Genesee, New York
Plan ID:H3362 - 017     Click to see other plans

Click here for the Independent Health Encompass 65 Basic (HMO-POS) enrollment options and to have a copy of this chart sent to your email. Enroll in Independent Health Encompass 65 Basic (HMO-POS)

— Plan Features —
Monthly Premium:$97.00 (See premium details below.)
Annual Rx Deductible:$0
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$6,700
Gap Coverage:Yes
Total Number of Formulary Drugs:5260    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$0.00$8.00$45.00$75.0033%
  — Number of Drugs per Tier:20621317842002137
Number of Members enrolled in this plan in your County:18,983 members
Plan’s Summary Star Rating: 4.50 out of 5 Stars.
   - Customer Service Rating: 3 out of 5 Stars.
   - Member Experience Rating: 5 out of 5 Stars.
   - Drug Cost Accuracy Rating: 4 out of 5 Stars.

— Plan Premium Details —
The Monthly Premium is Split as Follows:Total
Premium
Part C
Premium
Part D Base
Premium
Part D Supplemental
Premium
$97.00$39.50$57.50$0.00
Monthly Premium with Low-Income Subsidy:100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
$20.60$29.80$39.00$48.30

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$97 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:
  • $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.
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
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)$0$0
Tier 2 (Non-Preferred Generic)$8 copay$20 copay
Tier 3 (Preferred Brand)$45 copay$112.50 copay
Tier 4 (Non-Preferred Brand)$75 copay$187.50 copay
Tier 5 (Specialty Tier)33% of the costNot Offered
Standard Mail Order Cost-Sharing
TierThree-month supply
Tier 1 (Preferred Generic)$0
Tier 2 (Non-Preferred Generic)$20 copay
Tier 3 (Preferred Brand)$112.50 copay
Tier 4 (Non-Preferred Brand)$187.50 copay
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $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.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$0$0
Tier 2 (Non-Preferred Generic)Some$8 copay$20 copay
Standard Mail Order Cost-Sharing
TierDrugs CoveredThree-month supply
Tier 1 (Preferred Generic)All$0
Tier 2 (Non-Preferred Generic)Some$20 copay
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
$97 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:
  • $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
Ambulance Services
  • In-network:  $200 copay
  • Out-of-network:  20% of the cost
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:  20% 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:  $30-200 copay depending on the service
  • Out-of-network:  20% of the cost
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
  • Dental x-ray(s):
    • In-network:  You pay nothing. You are covered for up to 2.
  • Oral exam:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
  • Diabetes Supplies and Services
    Diabetes monitoring supplies:
    • In-network:  $10 copay
    • Out-of-network:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  20% of the cost
    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:  $100 copay
    • Out-of-network:  20% of the cost
    Diagnostic tests and procedures:
    • In-network:  $15-30 copay depending on the service
    • Out-of-network:  20% of the cost
    Lab services:
    • In-network:  You pay nothing
    • Out-of-network:  20% of the cost
    Outpatient x-rays:
    • In-network:  $30 copay
    • Out-of-network:  20% of the cost
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  $30 copay
    • Out-of-network:  20% of the cost
    Doctor’s Office Visits
    Primary care physician visit:
    • In-network:  $15 copay
    • Out-of-network:  $40 copay
    Specialist visit:
    • In-network:  $30 copay
    • Out-of-network:  $40 copay
    Durable Medical Equipment (wheelchairs, oxygen, etc.)
    • In-network:  10-20% of the cost depending on the equipment
    • Out-of-network:  20% 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:  $30 copay
    • Out-of-network:  20% of the cost
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $15-30 copay depending on the service
    • Out-of-network:  20% of the cost
    Routine hearing exam:
    • In-network:  $15-30 copay depending on the service
    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:  
      • $700 copay per stay
      • Outpatient group therapy visit:
        • In-network:  $40 copay
        • Out-of-network:  20% of the cost
        Outpatient individual therapy visit:
        • In-network:  $40 copay
        • Out-of-network:  20% 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:  20% of the cost
        Occupational therapy visit:
        • In-network:  $15 copay
        • Out-of-network:  20% of the cost
        Physical therapy and speech and language therapy visit:
        • In-network:  $15 copay
        • Out-of-network:  20% of the cost
        Outpatient Substance Abuse
        Group therapy visit:
        • In-network:  $40 copay
        • Out-of-network:  50% of the cost
        Individual therapy visit:
        • In-network:  $40 copay
        • Out-of-network:  50% of the cost
        Outpatient Surgery
        Ambulatory surgical center:
        • In-network:  $200 copay
        • Out-of-network:  20% of the cost
        Outpatient hospital:
        • In-network:  $0-200 copay depending on the service
        • Out-of-network:  20% of the cost
        Over-the-Counter Items
        Not Covered
        Prosthetic Devices (braces, artificial limbs, etc.)
        Prosthetic devices:
        • In-network:  0-20% of the cost depending on the device
        • Out-of-network:  20% of the cost
        Related medical supplies:
        • In-network:  You pay nothing
        • Out-of-network:  20% of the cost
        Renal Dialysis
        • In-network:  You pay nothing
        • Out-of-network:  You pay nothing
        Transportation
        Not covered
        Urgently Needed Care
        $50 copay
        Vision Services
        Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
        • In-network:  $30 copay
        • Out-of-network:  20% of the cost
        Routine eye exam:
        • In-network:  You pay nothing. You are covered for up to 1.
        Contact lenses:
        • In-network:  You pay nothing. You are covered for up to 1.
        Eyeglasses (frames and lenses):
        • In-network:  You pay nothing. You are covered for up to 1.
        Eyeglasses or contact lenses after cataract surgery:
        • In-network:  You pay nothing
        Our plan pays up to $150 for contact lenses and eyeglasses (frames and lenses) from an in-network 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:  20% 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:  
            • $700 copay per stay
          • You pay nothing per day for days 91 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 20
                • $50 copay per day for days 21 through 100
                Outpatient Prescription Drugs
                For Part B drugs such as chemotherapy drugs1:
                • In-network:  20% of the cost
                • Out-of-network:  30% of the cost
                Other Part B drugs1:
                • In-network:  20% of the cost
                • Out-of-network:  30% 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.
                Standard Retail Cost-Sharing
                TierOne-month supplyThree-month supply
                Tier 1 (Preferred Generic)$0$0
                Tier 2 (Non-Preferred Generic)$8 copay$20 copay
                Tier 3 (Preferred Brand)$45 copay$112.50 copay
                Tier 4 (Non-Preferred Brand)$75 copay$187.50 copay
                Tier 5 (Specialty Tier)33% of the costNot Offered
                Standard Mail Order Cost-Sharing
                TierThree-month supply
                Tier 1 (Preferred Generic)$0
                Tier 2 (Non-Preferred Generic)$20 copay
                Tier 3 (Preferred Brand)$112.50 copay
                Tier 4 (Non-Preferred Brand)$187.50 copay
                If you reside in a long-term care facility you pay the same as at a retail pharmacy.
                You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
                Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $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.

                Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
                Standard Retail Cost-Sharing
                TierDrugs CoveredOne-month supplyThree-month supply
                Tier 1 (Preferred Generic)All$0$0
                Tier 2 (Non-Preferred Generic)Some$8 copay$20 copay
                Standard Mail Order Cost-Sharing
                TierDrugs CoveredThree-month supply
                Tier 1 (Preferred Generic)All$0
                Tier 2 (Non-Preferred Generic)Some$20 copay
                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 copay
                • Out-of-network:  20% of the cost
                Diabetes self-management training:
                • In-network:  You pay nothing
                • Out-of-network:  20% of the cost
                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:  $30 copay
                • Out-of-network:  20% of the cost
                Hearing Services
                Exam to diagnose and treat hearing and balance issues:
                • In-network:  $15-30 copay depending on the service
                • Out-of-network:  20% of the cost
                Routine hearing exam:
                • In-network:  $15-30 copay depending on the service
                ** Outpatient Medical Services and Supplies **
                Outpatient Substance Abuse
                Group therapy visit:
                • In-network:  $40 copay
                • Out-of-network:  50% of the cost
                Individual therapy visit:
                • In-network:  $40 copay
                • Out-of-network:  50% of the cost
                Prosthetic Devices (braces, artificial limbs, etc.)
                Prosthetic devices:
                • In-network:  0-20% of the cost depending on the device
                • Out-of-network:  20% of the cost
                Related medical supplies:
                • In-network:  You pay nothing
                • Out-of-network:  20% of the cost
                ** Additional Benefits **
                Inpatient Mental Health Care
                For inpatient mental health care see the "Mental Health Care" section.

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