2019 Olympus Prime Constellation Health (PPO) H4876-003 By Constellation Health

2019 Medicare Advantage Plan Services for
Olympus Prime Constellation Health (PPO)


Olympus Prime Constellation Health (PPO) H4876-003 is a 2019 Medicare Advantage or Medicare Part-C plan by Constellation Health available to residents in Puerto Rico. This plan includes additional Medicare prescription drug (Part-D) coverage. The Olympus Prime Constellation Health (PPO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out of pocket. This can be a extremely nice safety net.

Olympus Prime Constellation Health (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Constellation Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Olympus Prime Constellation Health (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Constellation Health and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Constellation Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2019 Constellation Health Medicare Advantage Plan Details

Name:
Olympus Prime Constellation Health (PPO)
ID:
H4876-003
Provider:Constellation Health
Year:2019
Type: Local PPO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $3,400
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Initial Coverage Limit:$3820
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced






Part-C Premium

Constellation Health plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



Part-D Deductible and Premium

Olympus Prime Constellation Health (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Constellation Health plan offers a $0.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Constellation Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Olympus Prime Constellation Health (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00


Gap Coverage

In 2019 once you and your plan provider have spent $3820 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for brand-name drugs and 37% on generic drugs unless your plan offers additional coverage. This Constellation Health plan does offer additional coverage through the gap.





Plan Services




Health plan deductible


$0



Emergency care/Urgent care


Emergency $65 per visit (always covered)
Urgent care $0-65 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures Out-of-Network 20%
Diagnostic tests and procedures In-Network $0 copay
Lab services Out-of-Network 20%
Lab services In-Network $0 copay
Diagnostic radiology services (e.g., MRI) Out-of-Network 20%
Diagnostic radiology services (e.g., MRI) In-Network 10%
Outpatient x-rays Out-of-Network 20%
Outpatient x-rays In-Network 10%



Hearing


Hearing exam Out-of-Network 20%
Hearing exam In-Network $0 copay
Fitting/evaluation Not covered
Hearing aids Out-of-Network $0 copay
Hearing aids In-Network $0 copay



Preventive dental


Oral exam Out-of-Network 20%
Oral exam In-Network $0 copay
Cleaning Out-of-Network 20%
Cleaning In-Network $0 copay
Fluoride treatment Out-of-Network 20%
Fluoride treatment In-Network $0 copay
Dental x-ray(s) Out-of-Network 20%
Dental x-ray(s) In-Network $0 copay



Comprehensive dental


Non-routine services Not covered
Diagnostic services Out-of-Network $0 copay
Diagnostic services In-Network $0 copay
Restorative services Out-of-Network $0 copay
Restorative services In-Network $0 copay
Endodontics Out-of-Network $0 copay
Endodontics In-Network $0 copay
Periodontics Not covered
Extractions Out-of-Network $0 copay
Extractions In-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Out-of-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services In-Network $0 copay



Vision


Routine eye exam Out-of-Network 20%
Routine eye exam In-Network $0 copay
Other Out-of-Network 20%
Other In-Network $0 copay
Contact lenses Out-of-Network 20%
Contact lenses In-Network $0 copay
Eyeglasses (frames and lenses) Out-of-Network 20%
Eyeglasses (frames and lenses) In-Network $0 copay
Eyeglass frames Out-of-Network 20%
Eyeglass frames In-Network $0 copay
Eyeglass lenses Out-of-Network 20%
Eyeglass lenses In-Network $0 copay
Upgrades Not covered



Mental health services


Inpatient hospital - psychiatric Out-of-Network 20% per stay
Inpatient hospital - psychiatric In-Network $0 copay
Outpatient group therapy visit with a psychiatrist Out-of-Network 20%
Outpatient group therapy visit with a psychiatrist In-Network $10
Outpatient individual therapy visit with a psychiatrist Out-of-Network 20%
Outpatient individual therapy visit with a psychiatrist In-Network $10
Outpatient group therapy visit Out-of-Network 20%
Outpatient group therapy visit In-Network $10
Outpatient individual therapy visit Out-of-Network 20%
Outpatient individual therapy visit In-Network $10



Skilled Nursing Facility


Out-of-Network 20% per stay
In-Network $0 copay



Rehabilitation services


Occupational therapy visit Out-of-Network 20%
Occupational therapy visit In-Network $5
Physical therapy and speech and language therapy visit Out-of-Network 20%
Physical therapy and speech and language therapy visit In-Network $5



Ground ambulance


Out-of-Network 20%
In-Network $0 copay



Other health plan deductibles?


In-Network No



Transportation


Out-of-Network 20%
In-Network $0 copay



Foot care (podiatry services)


Foot exams and treatment Out-of-Network 20%
Foot exams and treatment In-Network $5
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 0-20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Diabetes supplies Out-of-Network 20% per item
Diabetes supplies In-Network $0 copay



Wellness programs (e.g., fitness, nursing hotline)


Covered



Medicare Part B drugs


Chemotherapy Out-of-Network 20%
Chemotherapy In-Network 20%
Other Part B drugs Out-of-Network 20%
Other Part B drugs In-Network 20%



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$5,100 In and Out-of-network
$3,400.01 In-network



Optional supplemental benefits


No



Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-Network No



Inpatient hospital coverage


Out-of-Network 20% per stay
In-Network $0 copay



Outpatient hospital coverage


Out-of-Network 20% per visit
In-Network $0 copay



Doctor visits


Primary Out-of-Network 20% per visit
Primary In-Network $0 copay
Specialist Out-of-Network 20% per visit
Specialist In-Network $10 per visit



Preventive care


Out-of-Network 20%
In-Network $0 copay






Coverage Area for Olympus Prime Constellation Health (PPO)

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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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