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)
$3,500 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
$280 for days 1 through 6
$0 for days 7 through 90
$0 for days 7 through 90
Outpatient hospital coverage
$300 or 20% per visit
Doctor visits
Primary:
$10 per visit
Specialist:
$40 per visit
$10 per visit
Specialist:
$40 per visit
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
20%
Lab services:
$10
Diagnostic radiology services (e.g., MRI):
$200-250
Outpatient x-rays:
$25
20%
Lab services:
$10
Diagnostic radiology services (e.g., MRI):
$200-250
Outpatient x-rays:
$25
Mental health services
$1,620 per stay
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
Skilled Nursing Facility
$0 for days 1 through 20
$167 for days 21 through 100
$167 for days 21 through 100
Rehabilitation services
Occupational therapy visit:
$40
Physical therapy and speech and language therapy visit:
$40
$40
Physical therapy and speech and language therapy visit:
$40
Ambulance
$290
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
$40
Routine foot care:
$40
$40
Routine foot care:
$40
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
0-20% per item
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
0-20% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%
20%
Other Part B drugs:
20%
Coverage Area for Coventry Total Care (HMO)
| State | Illinois |
|---|---|
| County | Cook |
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 | $2 copay |
| Tier 2: Non-Preferred Generic | $5 copay | $15 copay | $5 copay |
| Tier 3: Preferred Brand Name | $42 copay | $47 copay | $42 copay |
| Tier 4: Non-Preferred Brand Name | $100 copay | $100 copay | $100 copay |
| Tier 5: Specialty Tier | 33% coinsurance | 33% coinsurance | 33% 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 | $15 copay | $45 copay | $10 copay |
| Tier 3: Preferred Brand Name | $126 copay | $141 copay | $121 copay |
| Tier 4: Non-Preferred Brand Name | $300 copay | $300 copay | $300 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 Coventry Total Care (HMO) for Illinois
/
Details
SHERMI PARIKH, DPM
Phone Number
(773) 818-6622
Office Locations4255 W 63RD ST
CHICAGO, IL 60629
