Care Advantage (HMO SNP)

Do You Have Chronic Heart Failure and/or Diabetes?

This plan is available to anyone who has been diagnosed with chronic heart failure and/or diabetes. Our MedStar Medicare Choice Care Advantage (HMO SNP) plan offers

  • Free transportation to and from doctors’ appointments
  • Routine vision care
  • Preventive dental care
  • Membership to local fitness facilities
  • Care Advisory services to coordinate care
  • Nurse advice line available 24 hours a day, seven days a week
  • Prescription drug coverage for brand and generic drugs

2018 Plan Year

2018 MedStar Medicare Choice Care Advantage (HMO SNP) - Maryland

Benefit

MedStar Medicare Choice Care Advantage (HMO SNP)

Monthly Plan Premium

$27 in addition to your Medicare Part B premium

Annual Out-of-Pocket Maximum (your total yearly out-of-pocket costs)

$6,700 for all Medicare-covered benefits

Inpatient Hospital Care and Inpatient Mental Health Care

$350 copay per day (days 1-5), $0 copay per day (days 6-90, and beyond) / Acute

$300 copay per day (days 1-5), $0 copay per day (days 6-90, and beyond) / Mental Health

Skilled Nursing Facility (SNF)

$0 copay per day (days 1-20)

$167.50 copay per day (days 21-100)

Doctor Office Visits – Primary Care  Physician (PCP) and Specialist

$5 copay for each PCP visit

$50 copay for each specialist visit

Outpatient Rehabilitation (e.g., occupational, physical, speech and language therapy)

$40 copay per therapy visit

Outpatient Surgery

Ambulatory Surgical Center (ASC) – $350 copay per surgical procedure

Outpatient Hospital Facility – $400 copay per surgical procedure

Emergency Care

$80 copay per visit

Urgent Care

$50 copay per visit

Durable Medical Equipment

20% of the total cost per item

Diabetic Supplies

$0 copay for diabetic supplies

Lab Services, X-rays and Advanced Imaging Radiology Services (e.g., CT scans, MRI, MRA, PET scans, Nuclear Medicine and Stress tests)

$0 copay for lab services

$20 copay for general X-rays

$200 copay for the cost of each advanced imaging radiology service

20% of the total cost for diagnostic tests and procedures

Preventive Services

$0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap test, pelvic, prostate, colorectal exams, and bone mass measurement

Routine Vision

$0 copay for one routine eye exam per year

$100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year

Vision services covered only if provided by a network vision provider

Preventive Dental

$45 copay for routine preventive dental visit 
Covered routine preventive dental services include

  • Oral exam and cleaning - one every six months
  • Fluoride treatment - one per year
  • Dental X-ray - one per year

Dental services covered only if provided by a network vision provider

Fitness

$0 copay for fitness benefit when using a Silve&Fit network fitness center or gym

Transportation

$0 copay for up to 10 one-way trips to plan approved locations

Nurse Advice Line

Free access to healthcare advice and information from registered nurses, 24 hours a day, 7 days a week

Please note, not all plan benefits are listed above. You must continue to pay your Part B premium. For complete benefit information, please see the 2018 Summary of Benefits.

2018 Prescription Drug Coverage Focused on Your Health

The following chart shows the prescription drug coverage provided with our plan. It includes Part D prescription drug coverage with six levels of drug benefits

  • Preferred Generic Drugs

  • Generic Drugs
  • Preferred Brand Drugs
  • Non-Preferred Brand Drugs
  • Specialty Drugs
  • Select Diabetic Drugs

Make sure your prescriptions drug are covered.

2018 MedStar Medicare Choice Care Advantage (HMO SNP) - Maryland

There is a $405 Part D deductible applied to drugs on Tiers 3, 4, or 5 of the formulary.

Prescription Drug Tiers

One-Month Supply (up to 30 days)

Three-Month Supply (up to 90 days)

Tier 1: Preferred Generic Drugs

$4 copay

Standard Retail: $12 copay

Standard Mail-order: $10 copay

Tier 2: Generic Drugs

$15 copay

Standard Retail: $45 copay

Standard Mail-order: $37.50 copay

Tier 3: Preferred Brand Drugs

$47 copay

Standard Retail: $141 copay

Standard Mail-order: $117.50

Tier 4: Non-preferred Brand Drugs

$100 copay

Retail: $300 copay

Mail-order: $250 copay

Tier 5: Specialty Drugs 

25% coinsurance

Not offered

Tier 6: Select Diabetic Drugs

$10 copay

Standard Retail: $30 copay

Standard Mail-order: $25 copay

 

2017 Plan Year

2017 MedStar Medicare Choice Care Advantage (HMO SNP) - Maryland

Benefit

MedStar Medicare Choice Care Advantage (HMO SNP)

Monthly Plan Premium

$10 in addition to your Medicare Part B premium

Annual Out-of-Pocket Maximum (your total yearly out-of-pocket costs)

$6,700 for all Medicare-covered benefits

Inpatient Hospital Care and Inpatient Mental Health Care

$350 copay per day (days 1-5)  / Acute

$300 copay per day (days 1-5)  / Mental Health

Skilled Nursing Facility (SNF)

$0 copay per day (days 1-20)

$160 copay per day (days 2-100)

Doctor Office Visits – Primary Care  Physician (PCP) and Specialist

$5 copay for each PCP visit

$50 copay for each specialist visit

Outpatient Rehabilitation (e.g., occupational, physical, speech and language therapy)

$40 copay per therapy visit

Outpatient Surgery

Outpatient Hospital Facility – $350 copay per surgical procedure

Ambulatory Surgical Center (ASC) – $250 copay per surgical procedure

Emergency Care

$75 copay per visit

Urgent Care

$40 copay per visit

Durable Medical Equipment

20% of the cost per item

Diabetic Supplies

$0 copay for diabetic supplies

Lab Services, X-rays and Advanced Imaging Radiology Services (e.g., CT scans, MRI, MRA, PET scans, Nuclear Medicine and Stress tests)

$0 copay for lab services

$20 copay for general X-rays

$250 copay for the cost of each advanced imaging radiology service

Preventive Services

$0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap test, pelvic, prostate, colorectal exams, and bone mass measurement

Routine Vision

$0 copay for routine vision exams

$100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses  every year

Preventive Dental

$45 copay for routine preventive dental visit

Covered routine preventive dental services include:

  • Oral exam and cleaning - one every six months
  • Fluoride treatment - one per year
  • Dental X-ray - one per year

Fitness

$0 copay for fitness benefit when using a Silve&Fit network fitness center or gym

Transportation

$0 copay for up to 10 one-way trips

Nurse Advice Line

Free access to healthcare advice and information from registered nurses, 24 hours a day, 7 days a week

Care Advisory Services

Free support to coordinate care for complex health conditions

Please note, not all plan benefits are listed above. You must continue to pay your Part B premium. For complete benefit information, please see the 2017 Summary of Benefits.

2017 Prescription Drug Coverage Focused on Your Health

The following chart shows the prescription drug coverage provided with our plan. It includes Part D prescription drug coverage with six levels of drug benefits

  • Preferred generic drugs
  • Generic drugs
  • Preferred brand-name drugs
  • Non-preferred brand-name drugs
  • Specialty drugs
  • Preferred Diabetic Drugs

Make sure your prescriptions drug are covered.

2017 MedStar Medicare Choice Care Advantage (HMO SNP) - Maryland

There is a $200 Part D deductible applied to drugs on Tiers 3, 4, or 5 of the formulary.

Prescription Drugs

One-Month Supply (30 days)

Three-Month Supply (90 days)

Tier 1: Preferred Generic Drugs

$4 copay

Retail: $12 copay

Mail-order: $10 copay

Tier 2: Generic Drugs

$15 copay

Retail: $45 copay

Mail-order: $37.50 copay

Tier 3: Preferred Brand-Name Drugs

$47 copay

Retail: $141 copay

Mail-order: $117.50

Tier 4: Non-preferred Brand-Name Drugs

$100 copay

Retail: $300 copay

Mail-order: $250 copay

Tier 5: Specialty Drugs (one-month supply only)

29% of the cost

N/A

Tier 6: Preferred Diabetic Drugs

$10 copay

Retail: $30 copay

Mail-order: $25 copay

Coverage Gap

After total yearly drug costs reach $3,700, members will receive a discount on brand-name drugs and generally pay no more than 40% (plus dispensing fee) of the plan’s cost for brand drugs and 51% of the plan’s cost for generic drugs until the yearly out-of-pocket drug costs reach $4,950

Catastrophic Coverage

After the member’s yearly out-of-pocket drug costs reach $4,950

Generic drugs (including brand drugs treated as generic), either

  • $3.30 copay, or
  • 5% coinsurance

For all other drugs, either:

  • $8.25 copay, or
  • 5% coinsurance

 

 

Enroll in Plan Now

H9915_18_4013 -  Approved

Last Updated Date: 10/4/2017