PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
ESSENCE HEALTHCARE, INC.
CMS Rating
Plan Type
HMO
Annual Deductible
$0.00

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 been rated 5 stars by CMS
  • has no additional premium costs outside of your Medicare Part B premium
  • has a copay of $0 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
Monthly Drug Plan Premium
$0.00
Health Plan Deductible
$0
Choice of Doctors?
Plan Doctors for Most Services
Monthly Health Plan Premium
$0.00
Out-Of-Pocket Spending Limit
$2,300 In-network
Optional Supplemental Benefits?
No
Prescription Drugs Covered?
Yes
Other Health Plan Deductibles?
No

Benefits

Service
Cost
Ambulance
$200
Doctor's office visits
Primary Physician
$10 per visit
Specialist
$45 per visit
Durable medical equipment (wheelchairs, oxygen, etc.)
20% per item
Emergency care
$75 per visit (always covered)
Home health care
You pay nothing
Mental health care
$295 for days 1 through 6
$0 for days 7 through 90
Outpatient hospital
$250 or 20% per visit
Renal dialysis
20% per visit
Inpatient hospital care
$310 for days 1 through 7
$0 for days 8 through 90
Skilled Nursing Facility (SNF)
$40 for days 1 through 20
$125 for days 21 through 100

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$7 copay$7 copay
Tier 2: Non-Preferred Generic$0 copay$10 copay$10 copay
Tier 3: Preferred Brand Name$37 copay$42 copay$42 copay
Tier 4: Non-Preferred Brand Name$75 copay$85 copay$85 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$21 copay$21 copay
Tier 2: Non-Preferred Generic$0 copay$30 copay$30 copay
Tier 3: Preferred Brand Name$111 copay$126 copay$126 copay
Tier 4: Non-Preferred Brand Name$225 copay$255 copay$255 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
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
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

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