A non-government entity
Champion Health Plans-USA, LLC.
Plan ID: H6474-8-0
Plan Summary PageChampion Care (HMO C-SNP)
2026 Champion Care (HMO C-SNP) H6474 — 008 — 0 is a Medicare Advantage plan with drug coverage.
Learn more about Champion Care (HMO C-SNP) H6474 - 008 - 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.
$0.00 /mo
Monthly premium
$0
Drug deductible
$199.00
Out-of-pocket maximum (Out-of-Network)
Enroll online
Call to enroll
OR
Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
About This Plan
The Champion Care (HMO C-SNP) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care, specialists, preventive services, and routine diagnostic tests. Inpatient acute hospital stays, outpatient observation, and home health services also feature no copayments or coinsurance, though certain specialized care like outpatient hospital visits and psychiatric stays require flat copays. Emergency care is highly accessible with no copay for urgent care and a $70 copay for emergency room visits, which is waived upon hospital admission. This plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing services with no copayments, alongside a $3,000 annual dental maximum and a $335 eyewear allowance. Additionally, members can access up to 24 one-way transportation trips per year with no copay or coinsurance, as well as durable medical equipment with no copays and up to 20% coinsurance. While most routine care requires no out-of-pocket costs, select services like dialysis and prescription hearing aids carry predictable coinsurance or copayments.
The Champion Care (HMO C-SNP) plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately with no out-of-pocket deductible costs. For Tier 1 preferred generics and Tier 6 select care drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies, or for a 3-month supply through standard mail order. Tier 2 generic drugs are also highly affordable, requiring only a $3 copay for a 1-month supply at a standard pharmacy or a $6 copay for a 3-month standard mail order. For higher-tier medications, costs vary depending on the drug classification. Tier 3 preferred brands have a $47 copay for a 1-month standard pharmacy supply, while Tier 4 non-preferred brands carry a $100 copay for a 1-month supply. Tier 5 specialty drugs require a 33% coinsurance for a 1-month supply at standard pharmacies, which is the highest tier of coverage under this plan.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 Champion Care (HMO C-SNP) H6474 — 008 — 0 is a HMO C-SNP offered in CAR, CHU, CLA and WAS counties by Champion Health Plans-USA, LLC.. It has a monthly premium of $0.00.
Important:
2026 Champion Care (HMO C-SNP) H6474 — 008 — 0 is a Chronic or Disabling Condition Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Monthly plan premium
$0.00
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$199.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
Cardiovascular Disorders, Chronic Heart Failure, Diabetes
Plan Organization:
Champion Health Plans-USA, LLC.
Plan Type:
HMO C-SNP
Location:
CAR, CHU, CLA and WAS counties
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$0
Sign up for Champion Care (HMO C-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Champion Care (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$0
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 Full |
|---|---|
$0.00 | $0.00 |
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 $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | - | $0.00 copay | - | - |
2. Generic | - | $3.00 copay | - | - |
3. Preferred Brand | - | $47.00 copay | - | - |
4. Non-Preferred Brand | - | $100.00 copay | - | - |
5. Specialty Tier | - | 33% coinsurance | - | - |
6. Select Care Drugs | - | $0.00 copay | - | - |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
Champion Care (HMO C-SNP) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
| Days -: | |
|---|---|
| Copayment | 0.00 |
| Begin Day | 1 |
| End Day | 90 |
| Copayment | 0.00 |
| Begin Day | 1 |
| End Day | 60 |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
Yes
Additional Days for Inpatient Hospital-Acute
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
| Days -: | Days 11-90: | |
|---|---|---|
| Copayment | 100.00 | 0.00 |
| Begin Day | 1 | - |
| End Day | 10 | - |
| Copayment | 0.00 | - |
| Begin Day | 1 | - |
| End Day | 60 | - |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
Yes
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Observation Services
Observation Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Periodicity
Per stay
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Outpatient Blood Services
Outpatient Blood Services benefits are covered.
Cost Sharing:
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
Yes
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered.
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
Yes
Which Services have a Copayment
Medicare-covered Air Ambulance Services
Is this Copayment waived if admitted to hospital?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit (10b)
Plan Approved Health-related Location
Is there a service specific maximum plan benefit coverage amount?
No
Transportation Services - Plan Approved Health-related Location
Transportation Services - Plan Approved Health-related Location benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of trips
24
Periodicity
Every year
Type of transportation
One-way
Mode of Transportation
Rideshare Services, Bus/Subway, Van, Medical Transport, Other, Describe
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage?
Yes
Is the maximum plan benefit coverage amount unlimited?
No
Maximum amount
10000.00
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Routine Care, Other
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care
Routine Chiropractic Care benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Visits
20
Periodicity
Every year
Occupational Therapy Services
Occupational Therapy Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Podiatry Services
Not covered.
Other Health Care Professional
Other Health Care Professional benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Psychiatric Services
Psychiatric Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Psychiatric Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
7a: Primary Care Physician Services, 7b: Chiropractic Services, 7c: Occupational Therapy Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7e2: Group Sessions for Mental Health Specialty Services, 7f: Podiatry Services, 7g: Other Health Care Professional, 7h1: Individual Sessions for Psychiatric Services, 7h2: Group Sessions for Psychiatric Services, 7i: Physical Therapy and Speech-Language Pathology Services, 7k: Opioid Treatment Program Services, 9c1: Individual Sessions for Outpatient Substance Abuse, 9c2: Group Sessions for Outpatient Substance Abuse
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Other Defined Supplemental Benefits have a Copayment
14c1: Health Education, 14c7: Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)*, 14c8: Home and Bathroom Safety Devices and Modifications*, 14c11: Personal Emergency Response System (PERS), 14c16: Weight Management Programs*, 14c22: Support for Caregivers of Enrollees
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
Yes
Which Other Defined Supplemental Benefits have a Maximum Plan Benefit Coverage amount
14c4: Fitness Benefit*
Health Education
Health Education benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Personal Emergency Response System (PERS) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Weight Management Programs benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Support for Caregivers of Enrollees benefits are covered.
More Details:
Type of benefit for Support for Caregivers of Enrollees
Mandatory
Minimum copayment
0.00
Maximum copayment
0.00
Type of benefit offered for Support for Caregivers of Enrollees
Caregiver Training
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness
Maximum plan benefit coverage amount
35.00
Periodicity
Every month
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Home and Bathroom Safety Devices and Modifications
Home and Bathroom Safety Devices and Modifications benefits are covered.
More Details:
Maximum copayment
0.00
Minimum copayment
0.00
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Preventive Services
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Copayment
Medicare-covered Benefits, Routine Hearing Exams, Fitting/Evaluation for Hearing Aid
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Minimum copayment
0.00
Maximum copayment
0.00
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Minimum copayment
0.00
Maximum copayment
0.00
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every three years
Minimum copayment
149.00
Maximum copayment
149.00
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Copayment
Routine Eye Exams, Other
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Copayment
Medicare-covered Benefits, Contact lenses, Eyeglass lenses
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
335.00
Periodicity
Every year
Contact Lenses
Not covered.
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Eyeglass lenses
Not covered.
Eyeglass frames
Not covered.
Upgrades
Upgrades benefits are covered.
Cost Sharing:
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered.
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum amount
3000.00
Periodicity
Every year
Oral Exams
Oral Exams benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Other, Describe
Description
Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.
Dental X-Rays
Dental X-Rays benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years
Other Diagnostic Dental Services
Other Diagnostic Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Other, Describe
Description
Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year
Fluoride Treatment
Fluoride Treatment benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Other Preventive Dental Services
Other Preventive Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Covered under Diagnostic and Preventive Dental (16b)
Restorative Services
Restorative Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Adjunctive General Services
Not covered.
Endodontics
Endodontics benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Coinsurance percentage
20
Periodontics
Periodontics benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
20
Prosthodontics, removable
Prosthodontics, removable benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
40
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
40
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
3
Periodicity
Other, Describe
Description
Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.
Coinsurance percentage
20
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Copayment
Medicare-covered Diabetes Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
No
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetic Therapeutic Shoes/Inserts
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization and a doctor referral are required.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Copayment
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Procedures/Tests
Diagnostic Procedures/Tests benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Lab Services
Lab Services benefits are covered.
Cost Sharing:
All Radiological Services
All Radiological Services benefits are covered.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Copayment
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
Home Health Services
Home Health Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Copayment
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
| Days 1-20: | Days 21-100: | |
|---|---|---|
| Copayment | 0.00 | 218.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
Yes
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
30
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items
Not covered.
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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