PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
ALAMEDA ALLIANCE JOINT POWERS AUTHORITY (JPA)
CMS Rating
Plan Type
HMO SNP
Annual Drug Deductible
$310.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2014
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 In-Network
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
$0
Not Applicable
Inpatient Mental Health Care
$0
Not Applicable
Skilled Nursing Facility (SNF)
$0
Not Applicable
Home Health Care
$0
Not Applicable
Doctor Office Visits
$0
Not Applicable
Outpatient Services
$0
Not Applicable
Ambulance Services
$0
Not Applicable
Emergency Care
$0
Not Applicable
Durable Medical Equipment
$0
Not Applicable
Kidney Disease and Conditions
$0
Not Applicable
Specialist Office Visit
$0
Not Applicable

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

$0 yearly deductible for Medicare Part B drugs.*

$0 copay for Part B chemotherapy drugs and other Part-B drugs.*


Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://http://www.alliancecompletecare.org 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.


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 Alliance CompleteCare (HMO SNP) for certain drugs.

The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.

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.

In-Network

You pay a $0 annual deductible.

Initial Coverage

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 $1.20 copay; or
  • A $2.55 copay
For all other drugs, either:
  • A $0 copay; or
  • A $3.60 copay; or
  • A $6.35 copay.


Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

  • one-month (30-day) supply


  • three-month (90-day) supply


Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

  • one-month (31-day) supply of drugs



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

  • three-month (90-day) supply


Catastrophic Coverage

You pay a $0 copay.

Out-of-Network

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 Alliance CompleteCare (HMO SNP).

You can get out-of-network drugs the following way:

  • one-month (30-day) supply


Out-of-Network Initial Coverage

Depending on your income and institutional status, you will be reimbursed by Alliance CompleteCare (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 $1.20 copay; or
  • A $2.55 copay
For all other drugs purchased out-of-network, either:
  • A $0 copay; or
  • A $3.60 copay; or
  • A $6.35 copay.


Out-of-Network Catastrophic Coverage

You will be reimbursed in full for drugs purchased out-of-network.


Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

You must go to network doctors, specialists, and hospitals.

Referral required for network specialists (for certain benefits).


Inpatient Hospital Care



In-Network

Plan covers 90 days each benefit period.

$0 annual service category deductible*

$0 copay*

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Outpatient Care

Inpatient Mental Health Care



In-Network

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.

$0 annual service category deductible*

$0 copay*

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Skilled Nursing Facility (SNF)



General

Authorization rules may apply.

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

$0 annual service category deductible*

$0 copay for SNF services*


Home Health Care



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered home health visits*


Hospice



General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


Doctor Office Visits



General

Authorization rules may apply.

In-Network

$0 copay for each Medicare-covered primary care doctor visit.*

$0 copay for each Medicare-covered specialist visit.*


Outpatient Medical Services and Supplies

Chiropractic Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered chiropractic visits*

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


Podiatry Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered podiatry visits*

Medicare-covered podiatry visits are for medically necessary foot care.


Outpatient Mental Health Care



General

Authorization rules may apply.

In-Network

$0 copay for:

  • each Medicare-covered individual therapy visit*


  • each Medicare-covered group therapy visit*


$0 copay for:

  • each Medicare-covered individual therapy visit with a psychiatrist*


  • each Medicare-covered group therapy visit with a psychiatrist*


$0 copay for Medicare-covered partial hospitalization program services*


Outpatient Substance Abuse Care



General

Authorization rules may apply.

In-Network

$0 copay for:

  • each Medicare-covered individual substance abuse outpatient treatment visit*


  • each Medicare-covered group substance abuse outpatient treatment visit*



Outpatient Services



General

Authorization rules may apply.

In-Network

$0 copay for each Medicare-covered ambulatory surgical center visit*

$0 copay for each Medicare-covered outpatient hospital facility visit*


Ambulance Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered ambulance benefits.*


Emergency Care



General

$0 annual service category deductible*

$0 copay for Medicare-covered emergency room visits*

Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details.


Urgently Needed Care



General

$0 copay for Medicare-covered urgently-needed-care visits*


Outpatient Rehabilitation Services



General

Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

In-Network

$0 copay for Medicare-covered Occupational Therapy visits*

$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits*


Durable Medical Equipment



General

$0 annual service category deductible*

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered durable medical equipment*


Preventive Services

Prosthetic Devices



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered:

  • prosthetic devices*


  • medical supplies related to prosthetics, splints, and other devices*



Diabetes Programs and Supplies



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered Diabetes self-management training*

$0 copay for Medicare-covered:

  • Diabetes monitoring supplies*


  • Therapeutic shoes or inserts*



Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered:

  • lab services*


  • diagnostic procedures and tests*


  • X-rays*


  • diagnostic radiology services (not including X-rays)*


  • therapeutic radiology services*



Cardiac and Pulmonary Rehabilitation Services



General

Authorization rules may apply.

In-Network

$0 copay for:

  • Medicare-covered Cardiac Rehabilitation Services*


  • Medicare-covered Intensive Cardiac Rehabilitation Services*


  • Medicare-covered Pulmonary Rehabilitation Services*



Additional Benefits

Preventive Services



General

Authorization rules may apply.

$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.

Plan covers a physical exam annually.


Kidney Disease and Conditions



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered renal dialysis*

$0 copay for Medicare-covered kidney disease education services*


Dental Services



In-Network

$0 annual service category deductible for Medicare-covered dental benefits*

$0 copay for Medicare-covered dental benefits*

In general, preventive dental benefits (such as cleaning) not covered.


Hearing Services



In-Network

$0 annual service category deductible for Medicare-covered diagnostic hearing exams*

In general, supplemental routine hearing exams and hearing aids not covered.

$0 copay for: Medicare-covered diagnostic hearing exams*


Vision Services



In-Network

$0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk*

$0 copay for
  • one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery *


  • eyeglasses (lenses and frames)


  • contact lenses


  • eyeglass lenses


  • eyeglass frames


$75 plan coverage limit for supplemental eyewear every two years


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$0 copay$0 copayNot offered
Tier 2: Non-Preferred Generic$48 copay$48 copayNot offered
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$144 copay$144 copay$144 copay
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
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
Care for older adults – functional status assessment
Care for older adults – Pain screening
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
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

Physician Finder

Physicians that accept Alliance CompleteCare (HMO SNP) for California

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