Spartan IL I-SNP (HMO SNP)

Medicare Advantage Plan for Illinois

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderSunrise Advantage Plan
Plan IDH4778-1-0
CMS RatingNot Rated1
Plan TypeHMO SNP
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

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)
$3,400 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0 In-network
Monthly Drug Plan Premium
$27.50
Monthly Health Plan Premium
$0.00

Benefits

Service
Cost
Inpatient hospital coverage
$320 for days 1 through 5
$0 for days 6 through 90
Outpatient hospital coverage
$350 per visit
Doctor visits
Primary:
$0 copay
Specialist:
$30 per visit
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$50 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$30
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$50
Outpatient x-rays:
$10
Mental health services
$320 for days 1 through 5
$0 for days 6 through 90
Outpatient group therapy visit with a psychiatrist:
$30
Outpatient individual therapy visit with a psychiatrist:
$30
Outpatient group therapy visit:
$30
Outpatient individual therapy visit:
$30
Skilled Nursing Facility
$0 copay
Rehabilitation services
Occupational therapy visit:
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
Ambulance
$100
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
$0 copay
Routine foot care:
$0 copay
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 copay
Wellness programs (e.g., fitness, nursing hotline)
Not covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%

Coverage Area for Spartan IL I-SNP (HMO SNP)

StateIllinois
CountyCook

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offereds25% coinsuranceNot offered
Tier 2: Non-Preferred GenericNot offered25% coinsuranceNot offered
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered25% coinsuranceNot offered
Tier 2: Non-Preferred GenericNot offered25% coinsuranceNot offered
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier

Physician Finder

Physicians that accept Spartan IL I-SNP (HMO SNP) for Illinois

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