2019 Olympus Prime Constellation Health (PPO) H4876-3-0 in PR from Constellation Health | HealthPocket

Olympus Prime Constellation Health (PPO)

$0/mo

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Zip Code00926
Applicant1/19/1984 Male
Coverage Start1/20/2019
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderConstellation Health
Plan IDH4876-3-0
Plan Year2019
CMS RatingNot Rated
Plan TypePPO
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
  • has no additional premium costs outside of your Medicare Part B premium

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$0.00
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$5,100 In and Out-of-network
$3,400.01 In-network
Optional Supplemental BenefitsNo

Benefits

SERVICECOST
Inpatient hospital coverageIn-Network:$0 copay
Out-of-Network:20% per stay
Outpatient hospital coverageIn-Network:$0 copay
Out-of-Network:20% per visit
Doctor visitsPrimary:
In-Network:$0 copay
Out-of-Network:20% per visit
Specialist:
In-Network:$10 per visit
Out-of-Network:20% per visit
Preventive careIn-Network:$0 copay
Out-of-Network:20%
Emergency care/Urgent careEmergency:$65 per visit (always covered)
Urgent care:$0-65 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
In-Network:$0 copay
Out-of-Network:20%
Lab services:
In-Network:$0 copay
Out-of-Network:20%
Diagnostic radiology services (e.g., MRI):
In-Network:10%
Out-of-Network:20%
Outpatient x-rays:
In-Network:10%
Out-of-Network:20%
Mental health servicesInpatient hospital - psychiatric:
In-Network:$0 copay
Out-of-Network:20% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:$10
Out-of-Network:20%
Outpatient individual therapy visit with a psychiatrist:
In-Network:$10
Out-of-Network:20%
Outpatient group therapy visit:
In-Network:$10
Out-of-Network:20%
Outpatient individual therapy visit:
In-Network:$10
Out-of-Network:20%
Skilled Nursing FacilityIn-Network:$0 copay
Out-of-Network:20% per stay
Rehabilitation servicesOccupational therapy visit:
In-Network:$5
Out-of-Network:20%
Physical therapy and speech and language therapy visit:
In-Network:$5
Out-of-Network:20%
Ground ambulanceIn-Network:$0 copay
Out-of-Network:20%
TransportationIn-Network:$0 copay
Out-of-Network:20%
Foot care (podiatry services)Foot exams and treatment:
In-Network:$5
Out-of-Network:20%
Routine foot care:Not covered
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
In-Network:0-20% per item
Out-of-Network:20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:20% per item
Out-of-Network:20% per item
Diabetes supplies:
In-Network:$0 copay
Out-of-Network:20% per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:
In-Network:20%
Out-of-Network:20%
Other Part B drugs:
In-Network:20%
Out-of-Network:20%

Benefits Services

Hearing
Hearing examIn-Network: $0 copay
Out-of-Network: 20%
Fitting/evaluationNot covered
Hearing aidsIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Preventive Dental
Oral examIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
CleaningIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Fluoride treatmentIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Dental x-ray(s)In-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Comprehensive Dental
Non-routine servicesNot covered
Diagnostic servicesIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Restorative servicesIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
EndodonticsIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
PeriodonticsNot covered
ExtractionsIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Prosthodontics, other oral/maxillofacial surgery, other servicesIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Vision
Routine eye examIn-Network: $0 copay
Out-of-Network: 20%
OtherIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Contact lensesIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Eyeglasses (frames and lenses)In-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Eyeglass framesIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
Eyeglass lensesIn-Network: $0 copay
Out-of-Network: 20%
There may be limits on how much the plan will provide.
UpgradesNot covered

Coverage Area for Olympus Prime Constellation Health (PPO)

StatePuerto Rico
CountySan Juan

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 offereds$0 copayNot offered
Tier 2: Non-Preferred GenericNot offered$40 copayNot offered
Tier 3: Preferred Brand NameNot offered$75 copayNot offered
Tier 4: Non-Preferred Brand NameNot offered33% coinsuranceNot offered
Tier 5: Specialty Tier

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered$0 copayNot offered
Tier 2: Non-Preferred GenericNot offered$80 copayNot offered
Tier 3: Preferred Brand NameNot offered$150 copayNot offered
Tier 4: Non-Preferred Brand NameNot offered33% coinsuranceNot offered
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered$0 copayNot offered
Tier 2: Non-Preferred GenericNot offered$120 copayNot offered
Tier 3: Preferred Brand NameNot offered$225 copayNot offered
Tier 4: Non-Preferred Brand NameNot offered33% coinsuranceNot offered
Tier 5: Specialty Tier

Staying healthy - screenings, tests and vaccines

Breast cancer screeningNot Rated
Colorectal cancer screeningNot Rated
Annual flu vaccineNot Rated
Improving or maintaining physical healthNot Rated
Improving or maintaining mental healthNot Rated
Monitoring physical abilityNot Rated
Adult BMI assessmentNot Rated

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fractureNot Rated
Diabetes care – eye examNot Rated
Diabetes care – kidney disease monitoringNot Rated
Diabetes care – blood sugar controlledNot Rated
Controlling blood pressureNot Rated
Rheumatoid arthritis managementNot Rated
Reducing the risk of fallingNot Rated
Plan all-cause readmissionsNot Rated

Member Experience with Health Plan

Getting needed careNot Rated
Getting appointments and care quicklyNot Rated
Customer serviceNot Rated
Overall rating of health care qualityNot Rated
Overall rating of planNot Rated
Care CoordinationNot Rated

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health planNot Rated
Members choosing to leave the health planNot Rated
Beneficiary access and performance problemsNot Rated
Health plan quality improvementNot Rated

Health Plan Customer Service

Plan makes timely decision about appealsNot Rated
Reviewing appeals decisionsNot Rated
Call center – foreign language interpreter and TTY/TDD availability - MedicalNot Rated

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - DrugsNot Rated
Appeals auto-forwardNot Rated
Appeals upheldNot Rated

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug planNot Rated
Members choosing to leave the drug planNot Rated
Beneficiary access and performance problemsNot Rated
Drug plan quality improvementNot Rated

Member Experience with Drug Plan

Rating of drug planNot Rated
Getting needed prescription drugsNot Rated

Drug Pricing and Patient Safety

MPF Price AccuracyNot Rated
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

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.