CrestPoint Health Classic (PPO)

Medicare Advantage Plan (Part C w/ RX)

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Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
CrestPoint Health
CMS Rating
Not Rated
Plan Type
PPO
Annual Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage
  • This plan is available for 2015. see plan

Why We Like This Plan

  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium
  • gives you freedom to choose which doctors, specialist and hospitals you visit
  • Primary care physician office visit copay of $0
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

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
$3,400 In-Network$5,100 Out-of-Network$5,100 In and Out-of-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
Inpatient Hospital Care
Days 1-7: $225 copay per day. Days 8-90: $0 copay per day
Days 1-100: 50% of the cost per day
Inpatient Mental Health Care
Days 1-7: $225 copay per day. Days 8-90: $0 copay per day
Days 1-100: 50% of the cost per day
Skilled Nursing Facility (SNF)
Days 1-5: $25 copay per day. Days 6-20: $50 copay per day. Days 21-100: $150 copay per day
Days 1-100: 50% of the cost per SNF day
Home Health Care
0% maximum per visit
50% maximum per visit
Doctor Office Visits
$0
$30 maximum per visit
Outpatient Services
$250 maximum per visit
50% maximum per visit
Ambulance Services
$250 maximum
$250 maximum
Emergency Care
$65 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
50% maximum per item
Kidney Disease and Conditions
20% maximum per visit
50% maximum per visit
Specialist Office Visit
$25 maximum per visit
$35 maximum per visit

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.

30% 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.yourcrestpointhealth.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 both you and a Part D plan.

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 CrestPoint Health Classic (PPO) 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.

If you request a formulary exception for a drug and CrestPoint Health Classic (PPO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.

In-Network

$0 deductible.

Initial Coverage

You pay the following until total yearly drug costs reach $2,850:

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 from a preferred and non-preferred pharmacy the following way(s):

Tier 1: Preferred Generic

  • $0 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy


  • $5 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $12.50 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 2: Non-Preferred Generic

  • $5 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $12.50 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy


  • $15 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $37.50 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $112.50 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy


  • $45 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $112.50 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 4: Non-Preferred Brand

  • $95 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $237.50 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy


  • $95 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $237.50 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy


  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy


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):

Tier 1: Preferred Generic

  • $5 copay for a one-month (34-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $15 copay for a one-month (34-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (34-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $95 copay for a one-month (34-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (34-day) supply of drugs in this tier



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):

Tier 1: Preferred Generic

  • $12.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $37.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $112.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $237.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier


Coverage Gap

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


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 CrestPoint Health Classic (PPO).

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

Out-of-Network Initial Coverage

You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850:

Out-of-Network Initial Coverage

Tier 1: Preferred Generic

  • $5 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $15 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $95 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Out-of-Network Coverage Gap

You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.


Optional Supplemental Benefits

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.

Out of Service Area

Plan covers you when you travel in the U.S. or its territories.


,

Inpatient Hospital Care



In-Network

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

For Medicare-covered hospital stays:

  • Days 1 - 7: $225 copay per day


  • Days 8 - 90: $0 copay per day


$0 copay for additional non-Medicare-covered hospital days

Out-of-Network

For Medicare-covered hospital stays:

  • Days 1 - 100: 50% of the cost per day



Outpatient Care

Inpatient Mental Health Care



In-Network

Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.

For Medicare-covered hospital stays:

  • Days 1 - 7: $225 copay per day


  • Days 8 - 90: $0 copay per day


$0 copay for additional non-Medicare-covered hospital days

Out-of-Network

For Medicare-covered hospital stays:

  • Days 1 - 100: 50% of the cost per day



,

Skilled Nursing Facility (SNF)



In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For Medicare-covered SNF stays:

  • Days 1 - 5: $25 copay per day


  • Days 6 - 20: $50 copay per day


  • Days 21 - 100: $150 copay per day


Out-of-Network

For each Medicare-covered SNF stay:

  • Days 1 - 100: 50% of the cost per SNF day



,

Home Health Care



In-Network

0% of the cost for each Medicare-covered home health visit

Out-of-Network

50% of the cost 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.

$25 copay for each Medicare-covered specialist visit.

Out-of-Network

$30 copay for each Medicare-covered primary care doctor visit

$35 copay for each Medicare-covered specialist visit


Outpatient Medical Services and Supplies

Chiropractic Services



In-Network

$20 copay for each Medicare-covered chiropractic visit

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

50% of the cost for Medicare-covered chiropractic visits.


,

Podiatry Services



In-Network

$25 copay for each Medicare-covered podiatry visit

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

Out-of-Network

$35 copay for Medicare-covered podiatry visits


,

Outpatient Mental Health Care



In-Network

$25 copay for each Medicare-covered individual therapy visit

$25 copay for each Medicare-covered group therapy visit

$25 copay for each Medicare-covered individual therapy visit with a psychiatrist

$25 copay for each Medicare-covered group therapy visit with a psychiatrist

$55 copay for Medicare-covered partial hospitalization program services

Out-of-Network

50% of the cost for Medicare-covered partial hospitalization program services

$35 copay for Medicare-covered Mental Health visits with a psychiatrist

$35 copay for Medicare-covered Mental Health visits


,

Outpatient Substance Abuse Care



In-Network

$25 copay for Medicare-covered individual substance abuse outpatient treatment visits

$25 copay for Medicare-covered group substance abuse outpatient treatment visits

Out-of-Network

$35 copay for Medicare-covered substance abuse outpatient treatment visits


,

Outpatient Services



In-Network

$250 copay for each Medicare-covered ambulatory surgical center visit

$250 copay for each Medicare-covered outpatient hospital facility visit

Out-of-Network

50% of the cost for Medicare-covered outpatient hospital facility visits

50% of the cost for Medicare-covered ambulatory surgical center visits


,

Ambulance Services



In-Network

$250 copay for Medicare-covered ambulance benefits.

If you are admitted to the hospital, you pay $0 for Medicare-covered ambulance benefits.

Out-of-Network

$250 copay for Medicare-covered ambulance benefits.


,

Emergency Care



General

$65 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 23-hour(s) for the same condition, you pay $0 for the emergency room visit.


,

Urgently Needed Care



General

$65 copay for Medicare-covered urgently-needed-care visits


,

Outpatient Rehabilitation Services



General

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

In-Network

$30 copay for Medicare-covered Occupational Therapy visits

$30 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

Out-of-Network

50% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

50% of the cost for Medicare-covered Occupational Therapy visits.


,

Durable Medical Equipment



In-Network

20% of the cost for Medicare-covered durable medical equipment

Out-of-Network

50% of the cost for Medicare-covered durable medical equipment


Preventive Services

Prosthetic Devices



In-Network

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices

Out-of-Network

50% 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

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

Out-of-Network

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

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

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


,

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



In-Network

$15 copay for Medicare-covered lab services

$30 copay for Medicare-covered diagnostic procedures and tests

$15 copay for Medicare-covered X-rays

$200 copay for Medicare-covered diagnostic radiology services (not including X-rays)

$60 copay for Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $0 to $25 may apply

If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $0 to $25 may apply

Out-of-Network

50% of the cost for Medicare-covered therapeutic radiology services

50% of the cost for Medicare-covered outpatient X-rays

50% of the cost for Medicare-covered diagnostic radiology services

50% of the cost for Medicare-covered diagnostic procedures and tests

50% 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 $30 to $35 may apply


,

Cardiac and Pulmonary Rehabilitation Services



In-Network

$30 copay for Medicare-covered Cardiac Rehabilitation Services

$30 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$30 copay for Medicare-covered Pulmonary Rehabilitation Services

Out-of-Network

50% of the cost for Medicare-covered Cardiac Rehabilitation Services

50% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services

50% 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.

Out-of-Network

0% of the cost for Medicare-covered preventive services


,

Kidney Disease and Conditions



In-Network

20% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services

Out-of-Network

50% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services


,

Dental Services



In-Network

$0 copay for Medicare-covered dental benefits

$0 copay for the following preventive dental benefits:

  • oral exams


  • cleanings


  • fluoride treatments


  • dental x-rays


Out-of-Network

0% of the cost for Medicare-covered comprehensive dental benefits

0% of the cost for supplemental preventive dental benefits

$0 copay for supplemental preventive dental benefits

The plan will pay up to $100 for all of the following services combined: Supplemental
  • Preventive Dental


In and Out-of-Network

$100 plan coverage limit for supplemental preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.


,

Hearing Services



In-Network

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

$25 copay for Medicare-covered diagnostic hearing exams

Out-of-Network

$35 copay for Medicare-covered diagnostic hearing exams.


,

Vision Services



In-Network

$25 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$25 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


Out-of-Network

$35 copay for Medicare-covered eye exams

0% of the cost for Medicare-covered eyewear

$25 copay for supplemental routine eye exams


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$5 copayNot offered
Tier 2: Non-Preferred Generic$5 copay$15 copayNot offered
Tier 3: Preferred Brand Name$45 copay$45 copayNot offered
Tier 4: Non-Preferred Brand Name$95 copay$95 copayNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$12.5 copay$12.5 copay
Tier 2: Non-Preferred Generic$12.5 copay$37.5 copay$37.5 copay
Tier 3: Preferred Brand Name$112.5 copay$112.5 copay$112.5 copay
Tier 4: Non-Preferred Brand Name$237.5 copay$237.5 copay$237.5 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance

CMS Ratings

Staying healthy - screenings, tests and vaccines

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

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
Not Rated
Diabetes care – eye exam
Not Rated
Diabetes care – kidney disease monitoring
Not Rated
Diabetes care – blood sugar controlled
Not Rated
Diabetes care – cholesterol controlled
Not Rated
Controlling blood pressure
Not Rated
Rheumatoid arthritis management
Not Rated
Improving bladder control
Not Rated
Reducing the risk of falling
Not Rated
Plan all-cause readmissions
Not Rated

Ratings of Plan Responsiveness and Care

Getting needed care
Not Rated
Getting appointments and care quickly
Not Rated
Customer service
Not Rated
Overall rating of health care quality
Not Rated
Overall rating of plan
Not Rated

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

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

Physician Finder

Physicians that accept CrestPoint Health Classic (PPO) for Tennessee

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Community Q&A

Do you have questions about this plan?

Get answers from the HealthPocket community.
1 question| 1 answer
do you have to have a reforal to go to a specialest?
Q:
Asked by Anonymous 

1 answer

Know the Answer? Answer this Question
A: From the Plan Details page, it reads: Choice of Doctors?Any Doctor, normally no referral is required. Since we are an source of information and not a health plan or an insurance agent. If you would like to know more details, you may speak with a licensed agent for a quick update. The phone number and hours of operation is available when you click on 'Select'.
Answered on 2/7/2014 by davina

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