PARTCRX

Plan Summary

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

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
$5,000 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
$300 copay
Cost-sharing applies for one-way trip.
Doctors Office Visits
Primary care physician visit: $5 copay
Specialist visit: $35 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.
Our plan offers worldwide coverage for emergency services obtained
outside the U.S. and its territories.
Home Health Care
You pay nothing
If home health agency provides services in addition to skilled nursing or
therapy, separate cost sharing or authorization requirement may apply.
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital
stay.
  • $310 copay per day for days 1 through 5

  • You pay nothing per day for days 6 through 90

  • You pay nothing per day for days 91 and beyond

  • 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
    $300 per visit
    Renal dialysis
    20% per visit
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital
    stay.
  • $350 copay per day for days 1 through 5

  • You pay nothing per day for days 6 through 90

  • You pay nothing per day for days 91 and beyond

  • This benefit will begin on day one each time you are admitted to a specific
    facility type. A transfer within or to a facility, including Inpatient
    Rehabilitation, Long Term Acute Care, Inpatient Acute or Psychiatric facility
    is considered a new admission. 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
    You pay nothing for glucose monitors and diabetic test strips from our
    preferred vendor, OneTouch/LifeScan, and 20% of the cost from
    non-preferred vendors. A separate copayment may apply if your doctor
    provides services in addition to diabetes self-management training.
    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.
    Supplemental annual physical exam: You pay nothing; Fitness Benefit: You
    pay nothing
    Outpatient Substance Abuse
    Group therapy visit: $40 copay
    Individual therapy visit: $40 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): You pay nothing
    Occupational therapy visit: $40 copay
    Physical therapy and speech and language therapy visit: $40 copay
    How much is the deductible?
    $100 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): 20% of the cost
    Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including
    yearly glaucoma screening): 0-20% of the cost, depending on the service
    Routine eye exam (for up to 1 every year): You pay nothing
    Eyeglasses or contact lenses after cataract surgery: 20% of the cost
    Exam to diagnose and treat diseases and conditions of the eye 0% applies
    to yearly glaucoma screening. If a doctor provides services in addition to
    the exam to diagnose and treat diseases and conditions of the eye, a
    separate physician or facility cost share may apply (See Doctor’s office
    visit).
    Hearing Services
    Exam to diagnose and treat hearing and balance issues: 20% of the cost
    Prosthetic Devices (braces artificial limbs etc.)
    Prosthetic devices: 20% of the cost
    Related medical supplies: 20% of the cost
    Renal Dialysis
    20% of the cost
    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:
  • $5,000 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: $200 copay
    Outpatient hospital: $300 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): $350 copay
    Diagnostic tests and procedures: $35 copay
    Lab services: You pay nothing
    Outpatient x-rays: $20 copay
    Therapeutic radiology services (such as radiation treatment for cancer):
    $40 copay
    If a doctor provides services in addition to diagnostic tests and therapeutic
    services, a separate physician or facility cost share may apply. (See Doctor’s
    office visit or Outpatient Surgery/Outpatient hospital)
    Foot Care
    Foot exams and treatment if you have diabetes-related nerve damage
    and/or meet certain conditions: $40 copay
    Urgent Care
    $55 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$3 copay$10 copay$10 copay
    Tier 2: Non-Preferred Generic$8 copay$15 copay$15 copay
    Tier 3: Preferred Brand Name$47 copay$47 copay$47 copay
    Tier 4: Non-Preferred Brand Name50% coinsurance50% coinsurance50% coinsurance
    Tier 5: Specialty Tier30% coinsurance30% coinsurance30% coinsurance
    90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
    Tier 1: Preferred Generic$9 copay$30 copay$30 copay
    Tier 2: Non-Preferred Generic$24 copay$45 copay$45 copay
    Tier 3: Preferred Brand Name$141 copay$141 copay$141 copay
    Tier 4: Non-Preferred Brand Name50% coinsurance50% coinsurance50% coinsurance
    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
    Not Rated
    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
    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 Coventry Advantra Silver (HMO) for Nebraska

    /
    PRICKETT, WESLEY
    1513 N 60TH ST
    OMAHA, NE 68104
    SPECHT, PAT
    119 N 51ST ST
    OMAHA, NE 68132
    UYSAL, UTKU
    NEUROLOGICAL SCIENCES
    OMAHA, NE 68198
    LORENZO, AGAPITO
    988095 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    YOUNG, DAVID
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    GORDON, GREGORY
    981045 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    RADIO, STANLEY
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    HARRINGTON, JOHN
    EMILE 42ND ST
    OMAHA, NE 68198
    SANKARANENI, RAMMOHAN
    42 AND EMILE
    OMAHA, NE 68198
    LANDMARK, JAMES
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    BARES, SARA
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    LACROIX, CAROL
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    BARTHOLD, CLAUDIA
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    BURTON, BETH
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    PTACEK, TYLER
    984150 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    HEMSTREET, GEORGE
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    PIPINOS, IRAKLIS
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    THOMPSON, JONATHAN
    983280 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    WHEELOCK, LISA
    42ND AND EMILE
    OMAHA, NE 68198
    SALOMON, MICHAEL
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    HIMMELBERG, JEFFREY
    988095 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    DRAKE, MARY
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    THOMPSON, ROBERT
    EMILE 42ND ST
    OMAHA, NE 68198
    HANKINS, JORDAN
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    BURKE, WILLIAM
    988102 NEBRASKA MEDICAL CTR
    OMAHA, NE 68198
    Details
    WESLEY PRICKETT, M.D.
    Phone Number
    (402) 312-8658
    Office Locations
    1513 N 60TH ST
    OMAHA, NE 68104
    1513 N 60TH ST OMAHA NE, 68104

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