PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Leon Medical Centers, Cigna Healthspring
CMS Rating
Plan Type
HMO-POS
Annual Deductible
$100.00

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
  • has a copay of $1 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

All cost-sharing assumes in-network healthcare providers.

Plan Details

Costs and Other Important Information

Plan Year:
2016
Optional Supplemental Benefits?
Yes
Choice of Doctors?
Plan Doctors Only (some exceptions)
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
In-network: $250 copay or 20% of the cost, depending on the service
Out-of-network: $250 copay or 20% of the cost, depending on the service
Doctors Office Visits
Primary care physician visit:
In-network: You pay nothing
Out-of-network: 30% of the cost
Specialist visit:
In-network: $40 copay
Out-of-network: 30% of the cost
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: 30% 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:
· $245 copay per day for days 1 through 6
· You pay nothing per day for days 7 through 90
Out-of-network:
· 30% of the cost per stay
Outpatient group therapy visit:
In-network: $40 copay
Out-of-network: 30% of the cost
Outpatient individual therapy visit:
In-network: $40 copay
Out-of-network: 30% of the cost
Outpatient hospital
In-network: $250 per visit
Point of Service: 30% per visit
Renal dialysis
In-network: 20% per visit
Point of Service: 30% per visit
Inpatient Hospital Care
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:
· $280 copay per day for days 1 through 6
· You pay nothing per day for days 7 through 90
Out-of-network:
· 30% of the cost per stay
Diabetes Supplies and Services
Diabetes monitoring supplies:
In-network: 0-20% of the cost, depending on the supply
Out-of-network: 30% of the cost
Diabetes self-management training:
In-network: You pay nothing
Out-of-network: 30% of the cost
Therapeutic shoes or inserts:
In-network: 20% of the cost
Out-of-network: 30% of the cost
Acupuncture
Not covered
Preventive Care
In-network: You pay nothing
Out-of-network: 30% of the cost
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:
In-network: $40 copay
Out-of-network: 30% of the cost
Individual therapy visit:
In-network: $40 copay
Out-of-network: 30% of the cost
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: $20 copay
Out-of-network: 30% of the cost
Occupational therapy visit:
In-network: $40 copay
Out-of-network: 30% of the cost
Physical therapy and speech and language therapy visit:
In-network: $40 copay
Out-of-network: 30% of the cost
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.
Transportation
Not covered
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)
Diagnostic radiology services (such as MRIs, CT scans):
In-network: $45-200 copay, depending on the service
Out-of-network: 30% of the cost
Diagnostic tests and procedures:
In-network: $0-200 copay, depending on the service
Out-of-network: 30% of the cost
Lab services:
In-network: You pay nothing
Out-of-network: 30% of the cost
Outpatient x-rays:
In-network: $45 copay
Out-of-network: 30% of the cost
Therapeutic radiology services (such as radiation treatment for cancer):
In-network: $60 copay
Out-of-network: 30% of the cost
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):
In-network: $40 copay
Out-of-network: 30% of the cost
Preventive dental services:
Cleaning:
In-network: $0 copay. You are covered for up to 1 every six months.
Dental x-ray(s):
In-network: $0 copay. You are covered for up to 1 every year.
Oral exam:
In-network: $0 copay. You are covered for up to 1 every six months.
This plan offers additional dental benefits as an Optional Supplemental Benefit.
Vision Services
Exam to diagnose and treat diseases and conditions of the eye (including yearly
glaucoma screening):
In-network: $0-40 copay, depending on the service
Out-of-network: 30% of the cost
Routine eye exam:
In-network: $0 copay. You are covered for up to 1 visit(s) every year.
Contact lenses:
In-network: $0 copay
Eyeglasses (frames and lenses):
In-network: $0 copay. You are covered for up to 1 every year.
Eyeglass frames:
In-network: $0 copay. You are covered for up to 1 every year.
Eyeglass lenses:
In-network: $0 copay. You are covered for up to 1 every year.
Eyeglasses or contact lenses after cataract surgery:
In-network: $0 copay
Out-of-network: 30% of the cost
Our plan pays up to $100 every year for eyewear from an in-network provider. $0
copays for supplemental eyewear (except after cataract surgery) apply up to the
plan allowance. Please see your EOC for plan coverage details.
Hearing Services
Exam to diagnose and treat hearing and balance issues:
In-network: $0-40 copay, depending on the service
Out-of-network: 30% of the cost
Routine hearing exam:
In-network: $0 copay. You are covered for up to 1 every year.
Hearing aid fitting/evaluation:
In-network: $0 copay. You are covered for up to 1 every three years.
Hearing aid:
In-network: $0 copay
Our plan pays up to $500 every three years for hearing aids from an
in-network provider. Please see your EOC for plan coverage details.
Prosthetic Devices (braces artificial limbs etc.)
Prosthetic devices:
In-network: 20% of the cost
Out-of-network: 30% of the cost
Related medical supplies:
In-network: 20% of the cost
Out-of-network: 30% of the cost
Renal Dialysis
In-network: 20% of the cost
Out-of-network: 30% of the cost
Outpatient Surgery
Ambulatory surgical center:
In-network: $195 copay
Out-of-network: 30% of the cost
Outpatient hospital:
In-network: $250 copay
Out-of-network: 30% 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: 30% of the cost
Foot Care
Foot exams and treatment if you have diabetes-related nerve damage and/or
meet certain conditions:
In-network: $40 copay
Out-of-network: 30% of the cost
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.
In-network:
· You pay nothing per day for days 1 through 20
· $160 copay per day for days 21 through 100
Out-of-network:
· 30% of the cost per stay
Durable Medical Equipment (wheelchairs oxygen etc.)
In-network: 20% of the cost
Out-of-network: 30% 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$1 copay$1 copay$1 copay
Tier 2: Non-Preferred Generic$15 copay$15 copay$15 copay
Tier 3: Preferred Brand Name$47 copay$47 copay$47 copay
Tier 4: Non-Preferred Brand Name$95 copay$95 copay$95 copay
Tier 5: Specialty Tier30% coinsurance30% coinsurance30% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$2 copay$2 copay$2 copay
Tier 2: Non-Preferred Generic$30 copay$30 copay$30 copay
Tier 3: Preferred Brand Name$94 copay$94 copay$94 copay
Tier 4: Non-Preferred Brand Name$190 copay$190 copay$190 copay
Tier 5: Specialty Tier30% coinsurance30% coinsurance30% 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
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

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