Innovation Health Medicare Connection (HMO)

Medicare Advantage Plan for Virginia

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderInnovation Health
Plan IDH2829-1-0
CMS RatingNot Rated1
Plan TypeHMO
Annual Deductible$95.00

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

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
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
Cost
Inpatient hospital coverage
$225 for days 1 through 6
$0 for days 7 through 90
Outpatient hospital coverage
$50-275 per visit
Doctor visits
Primary:$5-25 per visit
Specialist:$35-50 per visit
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:$80 per visit (always covered)
Urgent care:$5-65 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:$50
Lab services:$10
Diagnostic radiology services (e.g., MRI):20%
Outpatient x-rays:$10
Mental health services
$318 for days 1 through 5
$0 for days 6 through 90
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
$164 for days 21 through 100
Rehabilitation services
Occupational therapy visit:$40
Physical therapy and speech and language therapy visit:$40
Ambulance
$400
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:$50
Routine foot care:Not covered
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
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:20%
Other Part B drugs:20%

Coverage Area for Innovation Health Medicare Connection (HMO)

StateVirginia
CountyChesapeake City

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$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 Tier31% coinsurance31% coinsurance31% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-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

Physician Finder

Physicians that accept Innovation Health Medicare Connection (HMO) for Virginia

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