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)
Not Applicable
Other health plan deductibles?
Yes
Health Plan Deductible
Coming soon
Monthly Drug Plan Premium
$92.40
Monthly Health Plan Premium
Not Applicable
Benefits
Service
Cost
Inpatient hospital coverage
Coming soon
Outpatient hospital coverage
20% per visit
Doctor visits
Primary:
20% per visit
Specialist:
20% per visit
20% per visit
Specialist:
20% per visit
Preventive care
20%
Emergency care/Urgent care
Emergency:
20%
Urgent care:
20%
20%
Urgent care:
20%
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
20%
Lab services:
20%
Diagnostic radiology services (e.g., MRI):
20%
Outpatient x-rays:
20%
20%
Lab services:
20%
Diagnostic radiology services (e.g., MRI):
20%
Outpatient x-rays:
20%
Mental health services
Coming soon
Outpatient group therapy visit with a psychiatrist:
20%
Outpatient individual therapy visit with a psychiatrist:
20%
Outpatient group therapy visit:
20%
Outpatient individual therapy visit:
20%
Outpatient group therapy visit with a psychiatrist:
20%
Outpatient individual therapy visit with a psychiatrist:
20%
Outpatient group therapy visit:
20%
Outpatient individual therapy visit:
20%
Skilled Nursing Facility
Coming soon
Rehabilitation services
Occupational therapy visit:
20%
Physical therapy and speech and language therapy visit:
20%
20%
Physical therapy and speech and language therapy visit:
20%
Ambulance
20%
Transportation
No
Foot care (podiatry services)
Foot exams and treatment:
20%
Routine foot care:
20%
20%
Routine foot care:
20%
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
20% per item
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
20% per item
Wellness programs (e.g., fitness, nursing hotline)
No
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%
20%
Other Part B drugs:
20%
Coverage Area for Express Scripts Medicare - Choice (PDP)
| State | Iowa |
|---|---|
| County | Polk |
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 | $2 copay | $10 copay | Not offered |
| Tier 2: Non-Preferred Generic | $7 copay | $20 copay | Not offered |
| Tier 3: Preferred Brand Name | $42 copay | $47 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | 48% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5: Specialty Tier | 26% coinsurance | 26% coinsurance | 26% coinsurance |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | $6 copay | $30 copay | $0 copay |
| Tier 2: Non-Preferred Generic | $21 copay | $60 copay | $4 copay |
| Tier 3: Preferred Brand Name | $126 copay | $141 copay | $126 copay |
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
CMS Ratings
Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availability - Drugs
Not Rated
Appeals auto-forward
Not Rated
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
