PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Universal American
CMS Rating
Plan Type
HMO-POS
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 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 Health Plan Premium
$0.00
Monthly Drug Plan Premium
$30.00
Health Plan Deductible
$0
Other Health Plan Deductibles?
No
Out-Of-Pocket Spending Limit
$3,400 In-network $10,000 Out-of-network
Prescription Drugs Covered?
Yes
Choice of Doctors?
Plan Doctors Only (some exceptions)
Optional Supplemental Benefits?
No

Benefits

Service
Cost
Ambulance Services
In-network: $150 copay
Out-of-network: $150 copay
Doctors Office Visits
Primary care physician visit:
In-network: You pay nothing
Out-of-network: $35 copay
Specialist visit:
In-network: $35 copay
Out-of-network: $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.
Worldwide Emergency: $75 copay for emergency service
outside of the U.S.A.; Worldwide Emergent Care coverage
includes emergency room visits, emergency hospital
admissions and ambulance trips where you are taken to the
emergency room up to $20,000 when outside the U.S.A.
Limited to 60 days coverage throughout the year.
Home Health Care
In-network: You pay nothing
Out-of-network: Not available
Part-time or intermittent Skilled Nursing and home health-aide
services, fewer than 8 hours a day and 35 hours per week,
including physical therapy, occupational therapy, and speech
therapy, medical and social services, medical equipment &
supplies.
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient
hospital stay.
In-network:
$200 copay per day for days 1 through 6
You pay nothing per day for days 7 through 90
You pay nothing per day for days 91 and beyond
Out-of-network:
40% of the cost per stay
Outpatient group therapy visit:
In-network: $30 copay
Out-of-network: $50 copay
Outpatient individual therapy visit:
In-network: $30 copay
Out-of-network: $50 copay
Outpatient hospital
In-network: $200 per visit
Point of Service: 40% per visit
Renal dialysis
In-network: 20% per visit
Inpatient Hospital Care
Our plan covers an unlimited number of days for an inpatient
hospital stay.
In-network:
$200 copay per day for days 1 through 6
You pay nothing per day for days 7 through 90
You pay nothing per day for days 91 and beyond
Acupuncture
Not covered
Diabetes Supplies and Services
Diabetes monitoring supplies:
In-network: 0-20% of the cost, depending on the supply
Out-of-network: 40% of the cost
Diabetes self-management training:
In-network: You pay nothing
Out-of-network: 40% of the cost
Therapeutic shoes or inserts:
In-network: 20% of the cost
Out-of-network: 40% of the cost
Covered diabetes supplies include: blood glucose monitor,
blood glucose test strips, lancet devices and lancets, and
glucose-control solutions for preferred brands.
Preventive Care
In-network: You pay nothing
Out-of-network: 40% 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.
*A colonoscopy or sigmoidoscopy conducted for polyp removal
or biopsy is a surgical procedure subject to the outpatient
surgery cost sharing described later in this benefit grid.
Outpatient Substance Abuse
Group therapy visit:
In-network: $30 copay
Out-of-network: $50 copay
Individual therapy visit:
In-network: $30 copay
Out-of-network: $50 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):
In-network: $30 copay
Out-of-network: $50 copay
Occupational therapy visit:
In-network: $30 copay
Out-of-network: $50 copay
Physical therapy and speech and language therapy visit:
In-network: $30 copay
Out-of-network: $50 copay
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):
In-network: $35 copay
Out-of-network: $50 copay
A single office visit that includes:
In-network: $15 copay
Cleaning (for up to 2 every year)
Dental x-ray(s) (for up to 2 every year)
Fluoride treatment (for up to 2 every year)
Oral exam (for up to 2 every year)
Out-of-network: Not available
Vision Services
Exam to diagnose and treat diseases and conditions of the eye
(including yearly glaucoma screening):
In-network: $0 copay
Out-of-network: $50 copay
Routine eye exam:
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: 40% of the cost
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: 20% of the cost
Out-of-network: 40% of the cost
Diagnostic tests and procedures:
In-network: You pay nothing
Out-of-network: 40% of the cost
Lab services:
In-network: You pay nothing
Out-of-network: 40% of the cost
Outpatient x-rays:
In-network: $16 copay
Out-of-network: $21 copay
Therapeutic radiology services (such as radiation treatment
for cancer):
In-network: 20% of the cost
Out-of-network: 40% of the cost
Hearing Services
Exam to diagnose and treat hearing and balance issues:
In-network: $30 copay
Out-of-network: $50 copay
Renal Dialysis
In-network: 20% of the cost
Out-of-network: Not available
Outpatient Surgery
Ambulatory surgical center:
In-network: $100 copay
Out-of-network: 40% of the cost
Outpatient hospital:
In-network: $200 copay
Out-of-network: 40% 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: $50 copay
Durable Medical Equipment
In-network: 20% of the cost
Out-of-network: Not available
Foot Care
Foot exams and treatment if you have diabetes-related nerve
damage and/or meet certain conditions:
In-network: $30 copay
Out-of-network: $50 copay
Urgent Care
$30 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
$150 copay per day for days 21 through 100
Prosthetic Devices
Prosthetic devices:
In-network: 20% of the cost
Out-of-network: 40% of the cost
Related medical supplies:
In-network: 20% of the cost
Out-of-network: 40% 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$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$5 copay$5 copay$5 copay
Tier 3: Preferred Brand Name$40 copay$40 copay$40 copay
Tier 4: Non-Preferred Brand Name$80 copay$80 copay$80 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$12.5 copay$12.5 copay$5 copay
Tier 3: Preferred Brand Name$100 copay$100 copay$80 copay
Tier 4: Non-Preferred Brand Name$200 copay$200 copay$160 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

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 TexanPlus Choice (HMO-POS) for Texas

/
SEBESTA, MICHAEL
3100 N LEE TREVINO DR STE G
EL PASO, TX 79936
Details
MICHAEL SEBESTA, MD
Phone Number
(915) 592-7400
Office Locations
3100 N LEE TREVINO DR STE G
EL PASO, TX 79936
3100 N LEE TREVINO DR STE G EL PASO TX, 79936

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