Summary of Benefits - coventry- · PDF filel Tier 1: $3 l Tier 2: $7 For all other formulary drugs, ... are getting are . Referrals from your PCP are not required for emergency care

Summary of Benefits
Advantra Option 1 (HMO-POS)
H2663, Plan 006
This is a summary of services covered by Advantra Option 1 (HMO-POS)
January 1, 2018 - December 31, 2018 Advantra Option 1 (HMO-POS) is a Medicare Advantage POS plan with a Medicare
contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It
does not list every service that we cover or list every limitation or exclusion. The plans
Evidence of Coverage provides a complete list of services we cover. The Evidence of
Coverage is available on our website or you may call us to request a copy. To join Advantra Option 1 (HMO-POS), you must be entitled to Medicare Part A, and be
enrolled in Medicare Part B, and live in our service area. Our service area includes the
following counties in
Illinois: Bond, Calhoun, Clinton, Greene, Jersey, Madison, Monroe, Randolph, St.
Clair, Washington
Missouri: Audrain, Boone, Callaway, Cole, Cooper, Crawford, Franklin, Gasconade,
Howard, Jefferson, Knox, Lincoln, Maries, Miller, Moniteau, Montgomery, Osage,
Perry, Pike, Shelby, St. Charles, St. Louis, St. Louis City, Ste. Genevieve, Warren,
Washington
H2
66
3.0
06
.1A
Y0001_2018_H2663_006_SB Accepted

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
Monthly Plan
Premium
$41 You must continue
to pay your
Medicare Part B
premium.
Deductible(s) This plan does not have a deductible.
Maximum
Out-of-Pocket
Responsibility
(does not
include
prescription
drugs)
$5,200 for in-network services annually The most you pay
for copays,
coinsurance and
other costs for
medical services for
the year.
Inpatient
Hospital
Coverage
$280 per day, days
1-7; $0 per day, days
8-90 You pay $0 per day for
days 91 and beyond.
30% per stay Prior authorization
may be required.
This benefit will
begin on day one
each time you are
admitted to a
specific facility
type. A transfer
within or to a
facility, including
Inpatient
Rehabilitation, Long
Term Acute Care,
Inpatient Acute or
Psychiatric facility is
considered a new
admission. You pay
your cost share per
admission.
Our plan covers an unlimited number of days
for an inpatient hospital stay.
Outpatient
Hospital
coverage
Outpatient hospital
observation services:
20% of the total cost
30% of the total cost Prior authorization
may be required.

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
Freestanding
ambulatory surgery
center: $200 copay Outpatient hospital
surgery: $300 copay
Doctor Visits
l Primary
Care
Physician
(PCP)
$25 copay per visit 30% of the total cost
per visit
You must choose an
in-network provider
to be your Primary
Care Provider (PCP).
l Specialists $50 copay per visit 30% of the total cost
per visit
Service may require
a referral from your
primary care
physician (PCP).
Preventive
Care
$0 copay 0% - 30% of the total
cost
Any additional
preventive services
approved by
Medicare during
the contract year
will be covered. Lower cost sharing
for Medicare -
covered
immunizations
out-of-network. Higher cost sharing
for all other
preventive benefits
out-of-network.
Emergency
Care
$80 copay per visit $80 copay for worldwide coverage
(emergency care outside of the United
States)
If you are admitted
to the hospital
within 24 hours,
you do not have to
pay your share of
the cost for
emergency care.

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
Urgently
Needed
Services
$65 copay for each urgent care facility visit $80 copay for urgent care worldwide (i.e.
outside of the United States)
Diagnostic
Services/Labs/
Imaging
Prior authorization
or physicians order
may be required.
l Diagnostic
radiology
services
(e.g., MRI)
$200 copay for CT
Scans
$275 copay for all
other diagnostic
radiology services
l Lab
services
$0 copay 30% of the total cost
l Diagnostic
tests and
procedures
l Outpatient
x-rays
Hearing
Services
l Medicare
covered
hearing
exam
$50 copay 30% of the total cost Service may require
primary care
physician (PCP).
l Routine
hearing
exam (one
exam every
year)
$0 copay Not Covered Service may require
primary care
physician (PCP).
l Hearing
aids
$0 copay Not Covered You are responsible
for any amount
over the hearing aid
coverage limit.
Our plan pays up to $500 (per ear) for
hearing aids every year Network: HCS Our plan has partnered with Hearing Care
Solutions (HCS) to provide your hearing aid

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
benefit. Call HCS at 1-855-268-6118 to
schedule an appointment.
Dental
Services
l Oral exam
& cleaning
Not Covered Not Covered
l Fillings Not Covered Not Covered
Vision
Services
l Medicare
covered
eye exams
$0 copay for glaucoma
screenings $0 copay for other
exams to diagnose
and treat diseases and
conditions of the eye
l Routine
eye exam
(one exam
every year)
l Contacts
and
Eyeglasses
(frames
and lenses)
Not Covered
l Eyeglasses
or contact
lenses after
cataract
surgery
Mental Health
Services
Prior authorization
may be required.
l Inpatient
visit
$1,620 per stay 30% per stay This benefit will
begin on day one
each time you are
admitted to a
specific facility

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
type. A transfer
within or to a
facility, including
Inpatient
Rehabilitation, Long
Term Acute Care,
Inpatient Acute or
Psychiatric facility is
considered a new
admission. You pay
your cost share per
admission.
l Outpatient
group
therapy
visit
l Outpatient
individual
therapy
Skilled
Nursing
Facility (SNF)
$0 per day, days 1-20;
$167 per day, days
21-100
30% per stay Our plan covers up
to 100 days in a
SNF. Prior
authorization may
be required.
Physical
therapy
$40 copay 30% of the total cost Prior authorization
may be required. Service may require
primary care
physician (PCP).
Ambulance
(one-way trip)
$250 copay $250 copay Prior authorization
is required for
non-emergency
transportation.
Transportation Not Covered Not Covered

Premium and
Benefits
Advantra Option 1
(HMO-POS)
In Network
Advantra Option 1
(HMO-POS)
Out-of- Network
What You Should
Know
Medicare Part
B Drugs
for chemotherapy
drugs 20% of the total cost
for other Part B drugs
30% of the total cost Prior authorization
may be required.
Outpatient Prescription Drugs
Deductible: This plan does not have a pharmacy deductible.
Initial Coverage Limit (ICL) - total amount you and the plan pay for prescription drugs before
you enter the coverage gap: $3,750
True Out-of-Pocket Threshold Amount (TrOOP) total amount you pay before reaching the
catastrophic coverage level: $5,000
Initial Coverage
Formulary: B2 Retail Rx 30-day
supply
Retail Rx 90-day
supply
Mail Order 90-day
supply
Tier 1: Preferred
Generic $3 $0 $0
Tier 2: Generic $7 $21 $16
T

Documents

Summary of Benefits - coventry- · PDF filel Tier 1: $3 l Tier 2: $7 For all other formulary drugs, ... are getting are . Referrals from your PCP are not required for emergency care