Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$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
Inpatient hospital coverage
$0 copay
Outpatient hospital coverage
$0 copay
Doctor visits
Primary:
$0 copay
Specialist:
$0 copay
$0 copay
Specialist:
$0 copay
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$0 copay
Urgent care:
$0 copay
$0 copay
Urgent care:
$0 copay
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
Mental health services
$0 copay
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$0 copay
Outpatient individual therapy visit:
$0 copay
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$0 copay
Outpatient individual therapy visit:
$0 copay
Skilled Nursing Facility
$0 copay
Rehabilitation services
Occupational therapy visit:
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
Ambulance
$0 copay
Transportation
$0 copay
Foot care (podiatry services)
Foot exams and treatment:
$0 copay
Routine foot care:
$0 copay
$0 copay
Routine foot care:
$0 copay
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)
Not covered
Medicare Part B drugs
Chemotherapy:
$0 copay
Other Part B drugs:
$0 copay
$0 copay
Other Part B drugs:
$0 copay
Coverage Area for PruittHealth Premier D-SNP (HMO SNP)
| State | Georgia |
|---|---|
| County | Gwinnett |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | 15% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | |||
| Tier 3: Preferred Brand Name | |||
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | 15% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | |||
| Tier 3: Preferred Brand Name | |||
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Breast cancer screening
Not Rated
Colorectal cancer screening
Not Rated
Annual flu vaccine
Not Rated
Improving or maintaining physical health
Not Rated
Improving or maintaining mental health
Not Rated
Monitoring physical ability
Not Rated
Adult BMI assessment
Not Rated
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
Not Rated
Diabetes care – eye exam
Not Rated
Diabetes care – kidney disease monitoring
Not Rated
Diabetes care – blood sugar controlled
Not Rated
Controlling blood pressure
Not Rated
Rheumatoid arthritis management
Not Rated
Reducing the risk of falling
Not Rated
Plan all-cause readmissions
Not Rated
Member Experience with Health Plan
Getting needed care
Not Rated
Getting appointments and care quickly
Not Rated
Customer service
Not Rated
Overall rating of health care quality
Not Rated
Overall rating of plan
Not Rated
Care Coordination
Not Rated
Member Complaints, and Changes in Health Plan's Performance
Complaints about the health plan
Not Rated
Members choosing to leave the health plan
Not Rated
Beneficiary access and performance problems
Not Rated
Health plan quality improvement
Not Rated
Health Plan Customer Service
Plan makes timely decision about appeals
Reviewing appeals decisions
Not Rated
Call center – foreign language interpreter and TTY/TDD availability - Medical
Not Rated
Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availability - Drugs
Not Rated
Appeals auto-forward
Appeals upheld
Member Complaints, and Changes in Drug Plan's Performance
Complaints about the drug plan
Not Rated
Members choosing to leave the drug plan
Not Rated
Beneficiary access and performance problems
Not Rated
Drug plan quality improvement
Not Rated
Member Experience with Drug Plan
Rating of drug plan
Getting needed prescription drugs
Not Rated
Drug Pricing and Patient Safety
MPF Price Accuracy
Not Rated
High risk medication
Not Rated
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Not Rated
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate
Physician Finder
Physicians that accept PruittHealth Premier D-SNP (HMO SNP) for Georgia
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