PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Coventry Health Care
CMS Rating
Plan Type
HMO
Annual Drug 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:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only (some exceptions)
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$3,400 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
$0Point of Service: Not Applicable
In Network: $0Point of Service: Not Applicable
Specialist Office Visit
$10 maximum per visit. Point of Service: 20% maximum per visit
In Network: $10 maximum per visit. Point of Service: 20% maximum per visit
Outpatient Services
$100 maximum per visit. Point of Service: 20% maximum per visit
In Network: $100 maximum per visit. Point of Service: 20% maximum per visit
Emergency Care
$65 maximum per visit. Point of Service: Not Applicable
In Network: $65 maximum per visit. Point of Service: Not Applicable
Ambulance Services
$100 maximum. Point of Service: Not Applicable
In Network: $100 maximum. Point of Service: Not Applicable
Kidney Disease and Conditions
20% maximum per visit. Point of Service: Not Applicable
In Network: 20% maximum per visit. Point of Service: Not Applicable
Home Health Care
$0Point of Service: Not Applicable
In Network: $0Point of Service: Not Applicable
Durable Medical Equipment
$0Point of Service: Not Applicable
In Network: $0Point of Service: Not Applicable
Inpatient Hospital Care
Days 1-10: $110 copay per day. Days 11-90: $0 copay per day. Point of Service: Not Applicable
In Network: Days 1-10: $110 copay per day. Days 11-90: $0 copay per day. Point of Service: Not Applicable
Skilled Nursing Facility (SNF)
Days 1-7: $10 copay per day. Days 8-20: $25 copay per day. Days 21-100: $100 copay per day. Point of Service: Not Applicable
In Network: Days 1-7: $10 copay per day. Days 8-20: $25 copay per day. Days 21-100: $100 copay per day. Point of Service: Not Applicable
Inpatient Mental Health Care
Days 1-10: $110 copay per day. Days 11-90: $0 copay per day. Point of Service: Not Applicable
In Network: Days 1-10: $110 copay per day. Days 11-90: $0 copay per day. Point of Service: 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$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$25 copay$30 copay$25 copay
Tier 3: Preferred Brand Name$60 copay$60 copay$60 copay
Tier 4: Non-Preferred Brand Name33% coinsurance33% coinsuranceNot offered
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$50 copay$60 copay$50 copay
Tier 3: Preferred Brand Name$180 copay$180 copay$180 copay
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
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 Coventry Summit Ideal (HMO) for Florida

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