PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Care Improvement Plus
CMS Rating
Plan Type
Regional PPO SNP
Annual 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?
Any Doctor
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$6,700 In-Network$6,700 In and Out-of-Network
Other Deductibles?
In Network: Yes. Out of Network: No
Health Plan Deductible
Coming Soon
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Coming Soon
Coming Soon
Inpatient Mental Health Care
Coming Soon
Coming Soon
Skilled Nursing Facility (SNF)
Coming Soon
Coming Soon
Home Health Care
$0
$0 maximum per visit
Doctor Office Visits
$0
20% maximum per visit
Outpatient Services
$0
20% maximum per visit
Ambulance Services
$0
20% maximum
Emergency Care
$0
Not Applicable
Durable Medical Equipment
$0
20% maximum per item
Kidney Disease and Conditions
$0
20% maximum per visit
Specialist Office Visit
$0
20% maximum per visit

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.*

20% of the cost for Medicare Part B drugs out-of-network.**


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://www.CareImprovementPlus.com 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 Care Improvement Plus Dual Advantage (Regional PPO SNP) for certain drugs.

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 Care Improvement Plus Dual Advantage (Regional PPO 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 Care Improvement Plus Dual Advantage (Regional PPO 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

No referral required for network doctors, specialists, and hospitals.

In and Out-of-Network

You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits.


Inpatient Hospital Care



In-Network

No limit to the number of days covered by the plan each hospital stay.

You will not be charged additional cost sharing for professional services.

$0 annual service category deductible*

$0 copay*

$0 copay for each additional non-Medicare-covered hospital day.

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*

You will not be charged additional cost sharing for professional services


Home Health Care



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered home health visits*

Out-of-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



In-Network

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

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

Out-of-Network

20% of the cost for each Medicare-covered primary care doctor visit**

20% of the cost for each Medicare-covered specialist visit**


Outpatient Medical Services and Supplies

Chiropractic Services



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).

Out-of-Network

20% of the cost for Medicare-covered chiropractic visits.**


Podiatry Services



In-Network

$0 copay for Medicare-covered podiatry visits*

$0 copay for up to 6 supplemental routine podiatry visit(s) every year

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

Out-of-Network

20% of the cost for Medicare-covered podiatry visits**

$0 copay for supplemental routine podiatry visits


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*

Out-of-Network

20% of the cost for Medicare-covered Mental Health visits with a psychiatrist**

20% of the cost for Medicare-covered Mental Health visits**

20% of the cost for Medicare-covered partial hospitalization program services**


Outpatient Substance Abuse Care



In-Network

$0 copay for:

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


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


Out-of-Network

20% of the cost for Medicare-covered substance abuse outpatient treatment visits**


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*

Out-of-Network

20% of the cost for Medicare-covered outpatient hospital facility visits**

20% of the cost for Medicare-covered ambulatory surgical center visits**


Ambulance Services



In-Network

$0 copay for Medicare-covered ambulance benefits.*

Out-of-Network

20% of the cost for Medicare-covered ambulance benefits.**


Emergency Care



General

$0 annual service category deductible*

$0 copay for Medicare-covered emergency room visits*

Worldwide coverage.

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.


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*

Out-of-Network

20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits**

20% of the cost for Medicare-covered Occupational Therapy visits.**


Durable Medical Equipment



General

$0 annual service category deductible*

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered durable medical equipment*

Out-of-Network

20% of the cost 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*


Out-of-Network

20% of the cost for Medicare-covered prosthetic devices.**


Diabetes Programs and Supplies



In-Network

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

$0 copay for Medicare-covered:

  • Diabetes monitoring supplies*


  • Therapeutic shoes or inserts*


Out-of-Network

20% of the cost for Medicare-covered Diabetes monitoring supplies**

20% of the cost for Medicare-covered Therapeutic shoes or inserts**

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


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*


Out-of-Network

20% of the cost for Medicare-covered therapeutic radiology services**

20% of the cost for Medicare-covered outpatient X-rays**

20% of the cost for Medicare-covered diagnostic radiology services**

20% of the cost for Medicare-covered diagnostic procedures and tests**

20% of the cost for Medicare-covered lab services**

If the doctor provides you services in addition to (Medicarecovered Diagnostic Procedures/Tests, Medicarecovered Laboratory Services, Diagnostic Radiological Services, Therapeutic Radiological Services, Outpatient X-Rays ), separate cost sharing of 0% or 20% of the cost may apply**


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*


Out-of-Network

20% of the cost for Medicare-covered Cardiac Rehabilitation Services**

20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services**

20% of the cost for Medicare-covered Pulmonary Rehabilitation Services**


Additional Benefits

Preventive Services



General

$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.

Out-of-Network

$0 copay for Medicare-covered preventive services**


Kidney Disease and Conditions



In-Network

$0 copay for Medicare-covered renal dialysis*

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

Out-of-Network

20% of the cost 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*

$0 copay for a supplemental visit that includes:

  • up to 1 oral exam(s) every year


  • up to 1 cleaning(s) every year


  • up to 1 dental x-ray(s) every year


Out-of-Network

20% of the cost for Medicare-covered comprehensive dental benefits**

$0 copay for supplemental preventive dental benefits


Hearing Services



In-Network

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

$0 copay for up to 1 supplemental routine hearing exam(s) every year

$380 copay each for up to 2 supplemental inner-ear hearing aid(s) every year

$330 copay each for up to 2 supplemental over-the-ear hearing aid(s) every year

Out-of-Network

20% of the cost for Medicare-covered diagnostic hearing exams.**

$0 copay for supplemental hearing exams.

$330 to $380 copay for supplemental hearing aids.


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 up to 1 supplemental routine eye exam(s) every year

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


$0 copay for eyeglasses (lenses and frames)

$0 copay for contact lenses

Out-of-Network

20% of the cost for Medicare-covered eyewear**

$0 copay for supplemental routine eye exams

$0 copay for supplemental eyewear

0% to 20% of the cost for Medicare-covered eye exams**

In and Out-of-Network

$125 plan coverage limit for supplemental eyewear every year. This limit applies to both in-network and out-of-network benefits.


Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offeredsNot offeredNot offered
Tier 2: Non-Preferred GenericNot offeredNot offeredNot offered
Tier 3: Preferred Brand NameNot offeredNot offeredNot offered
Tier 4: Non-Preferred Brand NameNot offeredNot offeredNot offered
Tier 5: Specialty TierNot offeredNot offeredNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offeredNot offeredNot offered
Tier 2: Non-Preferred GenericNot offeredNot offeredNot offered
Tier 3: Preferred Brand NameNot offeredNot offeredNot offered
Tier 4: Non-Preferred Brand NameNot offeredNot offeredNot offered
Tier 5: Specialty TierNot offeredNot offeredNot offered

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
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 Care Improvement Plus Dual Advantage (Regional PPO SNP) for Missouri

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