PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Coventry Health Care
CMS Rating
Plan Type
HMO
Annual Deductible
$185.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium

All cost-sharing assumes in-network healthcare providers.

Plan Details

Costs and Other Important Information

Plan Year:
2016
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors for Most Services
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$6,700 In-network
Other Health Plan Deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
Cost
Ambulance Services
$275 copay
If you are admitted to the hospital, you do not have to pay for the
ambulance services.
Non-emergency transportation requires prior authorization.
Doctors Office Visits
Primary care physician visit: $15 copay
Specialist visit: $50 copay
Emergency Care
$75 copay
If you are admitted to the hospital within 24 hours, you do not have to
pay your share of the cost for emergency care. See the "Inpatient Hospital
Care" section of this booklet for other costs.
Home Health Care
You pay nothing
Mental Health Care
Inpatient visit:
Our plan covers up to 190 days in a lifetime for inpatient mental health
care in a psychiatric hospital. The inpatient hospital care limit does not
apply to inpatient mental services provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are "extra" days
that we cover. If your hospital stay is longer than 90 days, you can use
these extra days. But once you have used up these extra 60 days, your
inpatient hospital coverage will be limited to 90 days.
  • $168 copay per day for days 1 through 9

  • You pay nothing per day for days 10 through 90

  • Outpatient group therapy visit: $40 copay
    Outpatient individual therapy visit: $40 copay
    Inpatient mental health hospitalization: You pay your cost share per
    admission
    Outpatient hospital
    $390 per visit
    Renal dialysis
    $10 per visit
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital
    stay.
  • $195 copay per day for days 1 through 9

  • You pay nothing per day for days 10 through 90

  • You pay nothing per day for days 91 and beyond

  • You pay your cost share per admission
    Diabetes Supplies and Services
    Diabetes monitoring supplies: 0-20% of the cost, depending on the supply
    Diabetes self-management training: You pay nothing
    Therapeutic shoes or inserts: 20% of the cost
    Our preferred vendor for diabetic supplies is One Touch/LifeScan. We
    require an authorization for glucose monitors and testing supplies from
    non-preferred vendors, test strips in excess of 100 per month (any brand),
    and diabetic therapeutic shoes or inserts.
    Acupuncture
    Not covered
    Preventive Care
    You pay nothing
    Our plan covers many preventive services, including:
  • Abdominal aortic aneurysm screening

  • Alcohol misuse counseling

  • Bone mass measurement

  • Breast cancer screening (mammogram)

  • Cardiovascular disease (behavioral therapy)

  • Cardiovascular screenings

  • Cervical and vaginal cancer screening

  • Colorectal cancer screenings (Colonoscopy, Fecal occult blood test,

  • Flexible sigmoidoscopy)
  • Depression screening

  • Diabetes screenings

  • HIV screening

  • Medical nutrition therapy services

  • Obesity screening and counseling

  • Prostate cancer screenings (PSA)

  • Sexually transmitted infections screening and counseling

  • Tobacco use cessation counseling (counseling for people with no sign

  • of tobacco-related disease)
  • Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

  • "Welcome to Medicare" preventive visit (one-time)

  • Yearly "Wellness" visit

  • Any additional preventive services approved by Medicare during the
    contract year will be covered.
    Outpatient Substance Abuse
    Group therapy visit: $45 copay
    Individual therapy visit: $45 copay
    Hospice
    You pay nothing for hospice care from a Medicare-certified hospice. You
    may have to pay part of the cost for drugs and respite care. Hospice is
    covered outside of our plan. Please contact us for more details.
    Outpatient Rehabilitation
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per
    day for up to 36 sessions up to 36 weeks): $5 copay
    Occupational therapy visit: $40 copay
    Physical therapy and speech and language therapy visit: $40 copay
    How much is the deductible?
    $185 per year for Part D prescription drugs except for drugs listed on Tier
  • and Tier 2 which are excluded from the deductible.
  • Transportation
    Not covered
    Over-the-Counter Items
    Not Covered
    Dental Services
    Limited dental services (this does not include services in connection with
    care, treatment, filling, removal, or replacement of teeth): $50 copay
    Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including
    yearly glaucoma screening): $0-50 copay, depending on the service
    Routine eye exam (for up to 1 every year): You pay nothing
    Eyeglasses or contact lenses after cataract surgery: You pay nothing
    $0 copay for Medicare-covered glaucoma screening, and the higher copay
    applies to all other Medicare-covered eye exams.
    Hearing Services
    Exam to diagnose and treat hearing and balance issues: $50 copay
    Routine hearing exam (for up to 1 every year): You pay nothing
    Prosthetic Devices (braces artificial limbs etc.)
    Prosthetic devices: 20% of the cost
    Related medical supplies: 20% of the cost
    Renal Dialysis
    $10 copay
    Is there a limit on how much the plan will pay?
    No. There are no limits on how much our plan will pay.
    How much is the monthly premium?
    $0 per month. In addition, you must keep paying your Medicare Part B
    premium.
    Is there any limit on how much I will pay for my covered services?
    Yes. Like all Medicare health plans, our plan protects you by having yearly
    limits on your out-of-pocket costs for medical and hospital care.
    Your yearly limit(s) in this plan:
  • $6,700 for services you receive from in-network providers.

  • If you reach the limit on out-of-pocket costs, you keep getting covered
    hospital and medical services and we will pay the full cost for the rest of
    the year.
    Please note that you will still need to pay your monthly premiums and
    cost-sharing for your Part D prescription drugs.
    Outpatient Surgery
    Ambulatory surgical center: $340 copay
    Outpatient hospital: $390 copay
    Chiropractic Care
    Manipulation of the spine to correct a subluxation (when 1 or more of the
    bones of your spine move out of position): $20 copay
    Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs, CT scans): $285 copay
    Diagnostic tests and procedures: $30 copay
    Lab services: $30 copay
    Outpatient x-rays: $30 copay
    Therapeutic radiology services (such as radiation treatment for cancer):
    $60 copay
    Foot Care
    Foot exams and treatment if you have diabetes-related nerve damage
    and/or meet certain conditions: $50 copay
    Routine foot care (for up to 1 visit(s) every three months): $50 copay
    Urgent Care
    $50 copay
    If you are admitted to the hospital within 24 hours, you do not have to
    pay your share of the cost for urgently needed services. See the "Inpatient
    Hospital Care" section of this booklet for other costs.
    Skilled Nursing Facility
    Our plan covers up to 100 days in a SNF.
  • You pay nothing per day for days 1 through 20

  • $160 copay per day for days 21 through 100
  • Durable Medical Equipment (wheelchairs oxygen etc.)
    20% of the cost

    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$5 copay$12 copay$12 copay
    Tier 2: Non-Preferred Generic$15 copay$20 copay$20 copay
    Tier 3: Preferred Brand Name$47 copay$47 copay$47 copay
    Tier 4: Non-Preferred Brand Name$100 copay$100 copay$100 copay
    Tier 5: Specialty Tier29% coinsurance29% coinsurance29% coinsurance
    90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
    Tier 1: Preferred Generic$12.5 copay$30 copay$30 copay
    Tier 2: Non-Preferred Generic$37.5 copay$50 copay$50 copay
    Tier 3: Preferred Brand Name$117.5 copay$117.5 copay$117.5 copay
    Tier 4: Non-Preferred Brand Name$300 copay$300 copay$300 copay
    Tier 5: Specialty Tier

    CMS Ratings

    Staying healthy - screenings, tests and vaccines

    Breast cancer screening
    Colorectal cancer screening
    Annual flu vaccine
    Improving or maintaining physical health
    Improving or maintaining mental health
    Monitoring physical ability
    Adult BMI assessment

    Managing Chronic Conditions

    Special needs plan care management
    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
    Controlling blood pressure
    Rheumatoid arthritis management
    Reducing the risk of falling
    Plan all-cause readmissions

    Member Experience with Health Plan

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

    Member Complaints, and Changes in Health Plan's Performance

    Complaints about the health plan
    Members choosing to leave the health plan
    Beneficiary access and performance problems
    Health plan quality improvement

    Health Plan Customer Service

    Plan makes timely decision about appeals
    Reviewing appeals decisions
    Call center – foreign language interpreter and TTY/TDD availability - Medical

    Drug Plan Customer Service

    Call center – foreign language interpreter and TTY/TDD availability - Drugs
    Appeals auto-forward
    Appeals upheld
    Not Rated

    Member Complaints, and Changes in Drug Plan's Performance

    Complaints about the drug plan
    Members choosing to leave the drug plan
    Beneficiary access and performance problems
    Drug plan quality improvement

    Member Experience with Drug Plan

    Rating of drug plan
    Getting needed prescription drugs

    Drug Pricing and Patient Safety

    MPF Price Accuracy
    High risk medication
    Part D medication adherence for diabetes
    Part D medication adherence for hypertension
    Part D medication adherence for cholesterol
    Medication Therapy Management program completion rate

    Physician Finder

    Physicians that accept Advantra Silver (HMO) for Pennsylvania

    /
    YOO, STANLEY
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    AHSAN, SYED
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    SRIDHARA, CHANNARAYAPATNA
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    BRADY, PAUL
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    MATSON, DAVID
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    VANGORE, SURYA
    431 W ROOSEVELT BLVD
    PHILADELPHIA, PA 19120
    GARCIA, LAUREANO
    328 W GODFREY AVE
    PHILADELPHIA, PA 19120
    WALSH, BRIAN
    4702 N 5TH ST
    PHILADELPHIA, PA 19120
    HOELLEIN, KENNETH
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    GRANT, RICHARD
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    LANOCE, GARY
    4857 C ST
    PHILADELPHIA, PA 19120
    SMALL, RONALD
    104 W CHELTENHAM AVE
    PHILADELPHIA, PA 19120
    STEERMAN, PAUL
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    WHYTE, JOHN
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    BLENDER, BURTON
    335 E WYOMING AVE
    PHILADELPHIA, PA 19120
    TADLEY, GERALD
    335 E WYOMING AVE
    PHILADELPHIA, PA 19120
    COSGROVE, DOUGLAS
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    SCHINDLER, ALAN
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    MYERS, JOHN
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    ROSENSTEIN, KENNETH
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    WIKOFF, EDWARD
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    SAMUELS, EYDA
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    ESQUENAZI, ALBERTO
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    MEHROTRA, DEEPAK
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    CLARKE, CLAUDINE
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    Details
    STANLEY YOO, MD
    Phone Number
    (215) 456-7000
    Office Locations
    101 E OLNEY AVE
    PHILADELPHIA, PA 19120
    101 E OLNEY AVE PHILADELPHIA PA, 19120

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