Liberty Advantage (HMO SNP)

Medicare Advantage Plan for North Carolina

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderLiberty Advantage (HMO SNP)
Plan IDH6351-1-0
CMS RatingNot Rated1
Plan TypeHMO SNP
Annual Deductible$405.00

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)
$6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
Coming soon
Monthly Drug Plan Premium
$30.10
Monthly Health Plan Premium
$0.00

Benefits

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

Coverage Area for Liberty Advantage (HMO SNP)

StateNorth Carolina
CountyCabarrus

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 Generic
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 Generic
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier

Physician Finder

Physicians that accept Liberty Advantage (HMO SNP) for North Carolina

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