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
$30.00
Monthly Health Plan Premium
$0.00
Benefits
Service
Cost
Inpatient hospital coverage
$320 for days 1 through 5
$0 for days 6 through 90
$0 for days 6 through 90
Outpatient hospital coverage
$350 per visit
Doctor visits
Primary:
$0 copay
Specialist:
$30 per visit
$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)
$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):
$40
Outpatient x-rays:
$10
$30
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$40
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
$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
$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
$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
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%
20%
Other Part B drugs:
20%
Coverage Area for Spartan VA I-SNP (HMO SNP)
| State | Virginia |
|---|---|
| County | Chesapeake City |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | 25% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | 25% coinsurance | Not offered |
| Tier 3: Preferred Brand Name | |||
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | 25% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | 25% coinsurance | Not offered |
| Tier 3: Preferred Brand Name | |||
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
Physician Finder
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