PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Care Improvement Plus
CMS Rating
Plan Type
Regional PPO
Annual Deductible
$220.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage
  • gives you freedom to choose which doctors, specialist and hospitals you visit

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?
Any Doctor
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$6,700 In and Out-of-network $6,700 In-network
Other Health Plan Deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$20.00
Monthly Health Plan Premium
$12.00

Benefits

Service
Cost
Ambulance Services
  • In-network: $250 copay

  • Out-of-network: $250 copay
  • Doctors Office Visits
    Primary care physician visit:
  • In-network: $15 copay

  • Out-of-network: $15 copay

  • Specialist visit:
  • In-network: $45 copay

  • Out-of-network: $45 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
  • In-network: You pay nothing

  • Out-of-network: 50% of the cost
  • 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.
  • In-network:

  • $395 copay per day for days 1 through 3

  • You pay nothing per day for days 4 through 90

  • Out-of-network:

  • $395 copay per day for days 1 through 3

  • You pay nothing per day for days 4 through 90

  • Outpatient group therapy visit:
  • In-network: $30 copay

  • Out-of-network: $30-40 copay, depending on the service

  • Outpatient individual therapy visit:
  • In-network: $40 copay

  • Out-of-network: $30-40 copay, depending on the service
  • Outpatient hospital
    In-network: 20% per visit
    Out-of-network: 20% per visit
    Renal dialysis
    In-network: 20% per visit
    Out-of-network: 20% per visit
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital
    stay.
  • In-network:

  • $395 copay per day for days 1 through 4

  • You pay nothing per day for days 5 through 90

  • You pay nothing per day for days 91 and beyond

  • Out-of-network:

  • $395 copay per day for days 1 through 4

  • You pay nothing per day for days 5 and beyond
  • Diabetes Supplies and Services
    Diabetes monitoring supplies:
  • In-network: You pay nothing

  • Out-of-network: 20% of the cost

  • Diabetes self-management training:
  • In-network: You pay nothing

  • Out-of-network: You pay nothing

  • Therapeutic shoes or inserts:
  • In-network: 20% of the cost

  • Out-of-network: 20% of the cost

  • The plan covers the following brands of blood glucose monitors and test
    strips: OneTouch UltraMini, OneTouch Ultra 2 System, OneTouch
    Verio IQ, OneTouch Verio Sync, ACCU-CHEK Nano SmartView,
    ACCU-CHEK Aviva Plus
    Acupuncture
    Not covered
    Preventive Care
  • In-network: You pay nothing

  • Out-of-network: 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.
    Over-the- Counter Items
    Not covered
    Outpatient Substance Abuse
    Group therapy visit:
  • In-network: $30 copay

  • Out-of-network: $30-40 copay, depending on the service

  • Individual therapy visit:
  • In-network: $40 copay

  • Out-of-network: $30-40 copay, depending on the service
  • 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):
  • In-network: $45 copay

  • Out-of-network: $45 copay

  • Occupational therapy visit:
  • In-network: $40 copay

  • Out-of-network: $40 copay

  • Physical therapy and speech and language therapy visit:
  • In-network: $40 copay

  • Out-of-network: $40 copay
  • Hospice
    You pay nothing for hospice care from a Medicare-certified hospice. You
    may have to pay part of the costs for drugs and respite care. Hospice is
    covered outside of our plan. Please contact us for more details.
    Transportation
    Not covered
    Dental Services
    Limited dental services (this does not include services in connection
    with care, treatment, filling, removal, or replacement of teeth):
  • In-network: $45 copay

  • Out-of-network: $45 copay

  • A single office visit that includes:
  • Cleaning (for up to 1 every year)

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

  • Oral exam (for up to 1 every year)

  • In-network: $20 copay

  • Out-of-network: $20 copay
  • Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including
    yearly glaucoma screening):
  • In-network: $0-45 copay, depending on the service

  • Out-of-network: $0-45 copay, depending on the service

  • Routine eye exam (for up to 1 every year):
  • In-network: $25 copay

  • Out-of-network: $25 copay

  • Contact lenses
  • In-network: $0 copay

  • Out-of-network: $0 copay

  • Eyeglasses (frames and lenses):
  • In-network: $0 copay

  • Out-of-network: $0 copay

  • Eyeglasses or contact lenses after cataract surgery:
  • In-network: You pay nothing

  • Out-of-network: You pay nothing

  • Our plan pays up to $100 every year for contact lenses and eyeglasses
    (frames and lenses) from any provider.
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:
  • In-network: $15 copay

  • Out-of-network: $15 copay

  • Routine hearing exam (for up to 1 every year):
  • In-network: $15 copay

  • Out-of-network: $15 copay

  • Hearing aid:
  • In-network: $330-380 copay for each hearing aid, depending on the

  • type
  • Out-of-network: $330-380 copay for each hearing aid, depending on

  • the type
    Renal Dialysis
  • In-network: 20% of the cost

  • Out-of-network: 20% of the cost
  • Chiropractic Care
    Manipulation of the spine to correct a subluxation (when 1 or more of the
    bones of your spine move out of position):
  • In-network: $20 copay

  • Out-of-network: $20 copay
  • Durable Medical Equipment
  • In-network: 20% of the cost

  • Out-of-network: 50% of the cost
  • Foot Care
    Foot exams and treatment if you have diabetes-related nerve damage
    and/or meet certain conditions:
  • In-network: $45 copay

  • Out-of-network: $45 copay

  • Routine foot care (for up to 6 visit(s) every year):
  • In-network: $45 copay

  • Out-of-network: $45 copay
  • Urgent Care
    $30-40 copay, depending on the service
    Skilled Nursing Facility
    Our plan covers up to 100 days in a SNF.
  • In-network:

  • You pay nothing per day for days 1 through 20

  • $160 copay per day for days 21 through 62

  • You pay nothing per day for days 63 through 100

  • Out-of-network:

  • You pay nothing per day for days 1 through 20

  • $160 copay per day for days 21 through 62

  • You pay nothing per day for days 63 through 100
  • Prosthetic Devices
    Prosthetic devices:
  • In-network: 20% of the cost

  • Out-of-network: 20% of the cost

  • Related medical supplies:
  • In-network: 20% of the cost

  • Out-of-network: 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$2 copay$2 copayNot offered
    Tier 2: Non-Preferred Generic$12 copay$12 copayNot offered
    Tier 3: Preferred Brand Name$47 copay$47 copayNot offered
    Tier 4: Non-Preferred Brand Name$100 copay$100 copayNot offered
    Tier 5: Specialty Tier28% coinsurance28% coinsuranceNot offered
    90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
    Tier 1: Preferred Generic$6 copay$6 copay$0 copay
    Tier 2: Non-Preferred Generic$36 copay$36 copay$0 copay
    Tier 3: Preferred Brand Name$141 copay$141 copay$131 copay
    Tier 4: Non-Preferred Brand Name$300 copay$300 copay$290 copay
    Tier 5: Specialty Tier28% coinsurance28% coinsurance28% coinsurance

    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

    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

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