PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Coventry Health Care
CMS Rating
Plan Type
HMO
Annual Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2013
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$6,700 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Doctor Office Visits
$20 maximum per visit
Not Applicable
Specialist Office Visit
$40 maximum per visit
Not Applicable
Outpatient Services
20% maximum per visit
Not Applicable
Emergency Care
$65 maximum per visit
Not Applicable
Ambulance Services
$250 maximum
Not Applicable
Kidney Disease and Conditions
20% maximum per visit
Not Applicable
Home Health Care
$0
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Inpatient Hospital Care
Days 1-5: $320 copay per day. Days 6-90: $0 copay per day
Not Applicable
Skilled Nursing Facility (SNF)
Days 1-20: $50 copay per day. Days 21-100: $150 copay per day
Not Applicable
Inpatient Mental Health Care
Days 1-7: $200 copay per day. Days 8-90: $0 copay per day
Not Applicable

Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$4 copay$9 copay$4 copay
Tier 2: Non-Preferred Generic$9 copay$9 copay$9 copay
Tier 3: Preferred Brand Name$45 copay$45 copay$45 copay
Tier 4: Non-Preferred Brand Name$95 copay$95 copay$95 copay
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$12 copay$27 copay$12 copay
Tier 2: Non-Preferred Generic$27 copay$27 copay$27 copay
Tier 3: Preferred Brand Name$135 copay$135 copay$135 copay
Tier 4: Non-Preferred Brand Name$285 copay$285 copay$285 copay
Tier 5: Specialty Tier

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Not Rated
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability
Not Rated

Physician Finder

Physicians that accept Coventry Advantra Silver (HMO) for Nebraska

/
ANDERSON, DERRICK
2734 N 61ST ST
OMAHA, NE 68104
YORK, GLENN
6069 MAPLE ST
OMAHA, NE 68104
GORDON, JOSETTE
2734 N 61ST ST
OMAHA, NE 68104
PRICKETT, WESLEY
1513 N 60TH ST
OMAHA, NE 68104
SPECHT, PAT
119 N 51ST ST
OMAHA, NE 68132
SAUER, TODD
702 N 58TH ST
OMAHA, NE 68132
FROCK, JAMES
7710 MERCY ROAD
OMAHA, NE 68132
MOORE, MICHAEL
119 N 51ST ST
OMAHA, NE 68132
HOBERMAN, CLAYTON
702 N 58TH ST
OMAHA, NE 68132
KRATOCHVIL, JILLYN
119 N 51ST ST
OMAHA, NE 68132
LOUCKS, ERIN
119 N 51ST ST
OMAHA, NE 68132
BICHALA, SHALINI
5002 UNDERWOOD AVE
OMAHA, NE 68132
CHRISTIANSEN FORD, CAREY
60 EXCHANGE ST STE B7
RICHMOND HILL, GA 31324
RODABAUGH, KERRY
988102 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
WESTER, REBECCA
989350 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
BAXTER, BERNARD
988102 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
GORDON, GREGORY
981045 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
ABDOUCH, IVAN
988095 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
ATTARD, THOMAS
988095 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
ARMITAGE, JAMES
988102 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
AOUN, PATRICIA
1500 DUARTE RD
DUARTE, CA 91010
BABBE, GREGORY
988095 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
BACKER, ELISABETH
988095 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
COLOMBO, JOHN
988102 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
BESSMER, JOEL
105 S 90TH ST STE 201
OMAHA, NE 68114
Details
DERRICK ANDERSON, MD
Phone Number
(402) 553-0222
Office Locations
2734 N 61ST ST
OMAHA, NE 68104
2734 N 61ST ST OMAHA NE, 68104

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