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PrimeTime Health Plan

Plan ID: H3664-20-0

PrimeTime Health Plan Classic (HMO-POS)

2024 PrimeTime Health Plan Classic (HMO-POS) H3664 — 020— 0 is a Medicare Advantage plan with drug coverage. It has received a 5-out-of-5 star rating from CMS for 2024.

Learn more about PrimeTime Health Plan Classic (HMO-POS) H3664 - 020 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

5 / 5 stars for 2024

$20.70 /mo

Monthly premium

Health deductible

Drug deductible

$4100.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 PrimeTime Health Plan Classic (HMO-POS) H3664 — 020— 0 is a Local HMO offered in Operating in 11 counties in Northeastern Ohio by PrimeTime Health Plan. It has a monthly premium of $39.00.

Premium Breakdown

Standard Part B Premium

$174.80

Part B premium reduction

Part C Premium

$18.30

Part D Basic Premium

$20.70

Part D Supplemental Premium

Part D Total

$20.70

Monthly Premium (Parts C & D)

$39.00

Total Premium (Parts B, C, & D)

$203.90

Special needs plan type

Out-of-pocket maximum

$4100.00

Plan Organization:

PrimeTime Health Plan

Plan Type:

Local HMO

Location:

Operating in 11 counties in Northeastern Ohio

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Plan Doctors Only (some exceptions)

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Drug deductible

Sign up for PrimeTime Health Plan Classic (HMO-POS)

Enroll online

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Drug Coverage

PrimeTime Health Plan Classic (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced

Prescription drug deductible

Increased initial coverage limit

Additional gap coverage

Yes

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$20.70	$20.70	$20.70	$20.70	$20.70

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	$0.00 copay	$10.00 copay	-	$0.00 copay
2. Standard Generic	$8.00 copay	$18.00 copay	-	$8.00 copay
3. Preferred Brand	$42.00 copay	$47.00 copay	-	$45.00 copay
4. Non-Preferred Drug	$95.00 copay	$100.00 copay	-	$95.00 copay
5. Specialty Tier	33%	33%	-	33%

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

30 Days

60 Days

90 Days

Tier	Preffered Pharmacy	Standard Pharmacy	Preffered Mail	Standard Mail
Preferred Generic	$0.00 copay	$10.00 copay	-	$0.00 copay
Generic	$8.00 copay	$18.00 copay	-	$8.00 copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

Additional Benefits

PrimeTime Health Plan Classic (HMO-POS) also provides the following benefits.

Comprehensive dental

Non-routine services

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic services

In-Network: $0 copay

Out-Of-Network: $0 copay

Restorative services

In-Network: $0 copay

Out-Of-Network: $0 copay

Endodontics

In-Network: $0 copay

Out-Of-Network: $0 copay

Periodontics

In-Network: $0 copay

Out-Of-Network: $0 copay

Extractions

In-Network: $0 copay

Out-Of-Network: $0 copay

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network: $0 copay

Out-Of-Network: $0 copay

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Cleaning

In-Network: $0 copay

Out-Of-Network: $0 copay

Fluoride treatment

In-Network: $0 copay

Out-Of-Network: $0 copay

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $80 copay

Lab services

In-Network: $0-5 copay

Out-Of-Network: $0-5 copay

Diagnostic radiology services (eg, MRI)

In-Network: $190 copay

Outpatient x-rays

In-Network: $80 copay

Doctor visits

Primary

In-Network: $0 copay

Specialist

In-Network: $35 copay per visit

Emergency care/Urgent care

Emergency

$110 copay per visit (always covered)

Urgent care

$40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $35 copay

Routine foot care

Not covered

Ground ambulance

Service

In-Network: $210 copay

Hearing

Hearing exam

In-Network: $5 copay

Fitting/evaluation

Not covered

Hearing aids

In-Network: $595-895 copay

Out-Of-Network: $0 copay

Inpatient hospital coverage

Service

In-Network: $295 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: Not Applicable

Outpatient hospital coverage

Service

In-Network: $300 copay or 25% coinsurance per visit

Outpatient prescription drugs

PrimeTime Health Plan Classic (HMO-POS) does not provide this type of benefit.

Optional benefits

PrimeTime Health Plan Classic (HMO-POS) does not provide this type of benefit.

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Diabetes supplies

In-Network: 0-20% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Part B Insulin drugs

In-Network: $35 copay

Mental health services

Inpatient hospital - psychiatric

In-Network: $295 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: Not Applicable

Outpatient group therapy visit with a psychiatrist

In-Network: $35 copay

Outpatient individual therapy visit with a psychiatrist

In-Network: $35 copay

Outpatient group therapy visit

In-Network: $35 copay

Outpatient individual therapy visit

In-Network: $35 copay

Preventive care

Service

In-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: $30 copay

Physical therapy and speech and language therapy visit

In-Network: $30 copay

Skilled Nursing Facility

Service

In-Network: $0 per day for days 1 through 20 $135 per day for days 21 through 45 $0 per day for days 46 through 100

Out-Of-Network: Not Applicable

Transportation

Service

Not covered

Vision

Routine eye exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Other

Not covered

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

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