Coventry Total Care (PPO)

Medicare Advantage Plan for South Dakota

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Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderAetna
Plan IDH1608-4-0
CMS Rating1
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
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

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)
$7,500 In and Out-of-network $5,400 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
In-Network:
$450 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
45% for days 1 and beyond
Outpatient hospital coverage
In-Network:
$250 per visit
Out-of-Network:
45% per visit
Doctor visits
Primary:
In-Network:
$7 per visit
Out-of-Network:
45% per visit
Specialist:
In-Network:
$30 per visit
Out-of-Network:
45% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
0-45%
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$55 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
$30
Out-of-Network:
45%
Lab services:
In-Network:
$0 copay
Out-of-Network:
45%
Diagnostic radiology services (e.g., MRI):
In-Network:
$175
Out-of-Network:
45%
Outpatient x-rays:
In-Network:
$15
Out-of-Network:
45%
Mental health services
In-Network:
$305 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
45% for days 1 and beyond
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
45%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
45%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
45%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
45%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$160 for days 21 through 100
Out-of-Network:
45% for days 1 through 100
Rehabilitation services
Occupational therapy visit:
In-Network:
$40
Out-of-Network:
45%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
45%
Ambulance
In-Network:
$305
Out-of-Network:
$305
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$30
Out-of-Network:
45%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
40% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
0-20% per item
Out-of-Network:
0-20% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
45%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
45%

Coverage Area for Coventry Total Care (PPO)

StateSouth Dakota
CountyLincoln

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 Generic$0 copay$10 copay$0 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 Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 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 (PPO) for South Dakota

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FEISTNER-LEUNING, HEIDI
6000 W 41ST ST
SIOUX FALLS, SD 57106
UTHE, CRAIG
3401 W 49TH ST
SIOUX FALLS, SD 57106
BROOKS, PATRICIA
3401 W 49TH ST
SIOUX FALLS, SD 57106
HULTGREN, KARI
6000 W 41ST ST
SIOUX FALLS, SD 57106
BOYENS, SCOTT
3401 W 49TH ST
SIOUX FALLS, SD 57106
SORENSEN, TODD
3401 W 49TH ST
SIOUX FALLS, SD 57106
DONELAN, TIMOTHY
3401 W 49TH ST
SIOUX FALLS, SD 57106
PEDERSON, KIM
6000 W 41ST ST
SIOUX FALLS, SD 57106
MEYER, JEFFRY
3401 W 49TH ST
SIOUX FALLS, SD 57106
PALMER, BRADLEY
7220 W 41ST ST
SIOUX FALLS, SD 57106
DAY, RICHARD
7220 W 41ST ST
SIOUX FALLS, SD 57106
PETERSON-HENRY, TERRI
7220 W 41ST ST
SIOUX FALLS, SD 57106
DEHAAN, DOUGLAS
7220 W 41ST ST
SIOUX FALLS, SD 57106
JUNDT, KIM
2100 S MARION RD
SIOUX FALLS, SD 57106
RODRIGUEZ, GABRIEL
3900 W 41ST ST
SIOUX FALLS, SD 57106
WURTH, JASON
3401 W 49TH ST
SIOUX FALLS, SD 57106
RECTOR, MARK
3401 W 49TH ST
SIOUX FALLS, SD 57106
LARSON, LORILEE
6100 W 41ST ST STE 102
SIOUX FALLS, SD 57106
DILLON, BONNIE
5837 KING ARTHUR DRIVE
SIOUX FALLS, SD 57106
CARLSON, CARRIE
6000 W 41ST ST
SIOUX FALLS, SD 57106
LARSEN, DAVID
6000 W 41ST ST
SIOUX FALLS, SD 57106
BOSCHEE, CHRISTOPHER
7220 W 41ST ST
SIOUX FALLS, SD 57106
STOTZ, KIRSTEN
4011 W BENSON RD
SIOUX FALLS, SD 57107
CULEY, SHAWN
4011 W BENSON RD
SIOUX FALLS, SD 57107
ANDERSON, KEITH
1305 W 18TH ST
SIOUX FALLS, SD 57105
Details
HEIDI FEISTNER-LEUNING, M.D.
Phone Number
(605) 361-7208
Office Locations
6000 W 41ST ST
SIOUX FALLS, SD 57106
6000 W 41ST ST SIOUX FALLS SD, 57106

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