2019 Tribute (HMO-POS SNP) DS-H1587

Tribute (HMO-POS SNP) By Superior Select Health Plans

Tribute (HMO-POS SNP) is a 2019 Medicare Advantage Special Needs Plan plan by Superior Select Health Plans. This plan from Superior Select Health Plans works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Superior Select Health Plans and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Tribute (HMO-POS SNP) DS-H1587 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.

2019 Medicare Special Needs Plan Details

Plan Name:
Tribute (HMO-POS SNP)
Plan ID:
Special Needs Type: Dual-Eligible
Provider: Superior Select Health Plans
Plan Year:2019
Plan Type: Local HMO
Monthly Premium C+D: $23.90


The Tribute (HMO-POS SNP) DS-H1587 is available to residents in Arkansas, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Tribute (HMO-POS SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.

Part-C Premium

Superior Select Health Plans 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

The Tribute (HMO-POS SNP) plan has a monthly drug premium of $23.90 and a $415.00 drug deductible. This Superior Select Health Plans plan offers a $23.90 Part D Basic Premium that is 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 Superior Select Health Plans 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 $23.90. 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 Tribute (HMO-POS SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.00 for 75% low income subsidy $11.90 for 50% and $17.90 for 25%.

Part C Premium: $0.00
Part D (Drug) Premium: $23.90
Part D Supplemental Premium $0.00
Total Part D Premium: $23.90
Drug Deductible: $415.00
Tiers with No Deductible: 0
Benchmark: below the regional benchmark
Type of Medicare Health Plan: Defined Standard Benefit
Drug Benefit Type: Basic
Full LIS Premium: $0.00
75% LIS Premium: $6.00
50% LIS Premium: $11.90
25% LIS Premium: $17.90
Initial Coverage Limit:$3820
Gap Coverage: No

Gap Coverage

In 2019 once you and your plan provider have spent $3,820 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 Superior Select Health Plans plan does not offer additional coverage through the gap.

Plan Services

Health plan deductible


Emergency care/Urgent care

Emergency $0 copay
Urgent care $0 copay

Diagnostic procedures/lab services/imaging

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


Hearing exam In-Network $0 copay
Fitting/evaluation Out-of-Network $0 copay
Fitting/evaluation In-Network $0 copay
Hearing aids Out-of-Network $0 copay
Hearing aids In-Network $0 copay

Preventive dental

Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered

Comprehensive dental

Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered


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

Mental health services

Inpatient hospital - psychiatric Out-of-Network Not Applicable
Inpatient hospital - psychiatric In-Network $0 copay
Outpatient group therapy visit with a psychiatrist In-Network $0 copay
Outpatient individual therapy visit with a psychiatrist In-Network $0 copay
Outpatient group therapy visit In-Network $0 copay
Outpatient individual therapy visit In-Network $0 copay

Skilled Nursing Facility

Out-of-Network Not Applicable
In-Network $0 copay

Rehabilitation services

Occupational therapy visit In-Network $0 copay
Physical therapy and speech and language therapy visit In-Network $0 copay

Ground ambulance

In-Network $0 copay

Other health plan deductibles?

In-Network No


Not covered

Foot care (podiatry services)

Foot exams and treatment In-Network $0 copay
Routine foot care Not covered

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen) In-Network $0 copay
Prosthetics (e.g., braces, artificial limbs) In-Network $0 copay
Diabetes supplies In-Network $0 copay

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


Medicare Part B drugs

Chemotherapy In-Network $0 copay
Other Part B drugs In-Network $0 copay

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

$6,700 In-network

Optional supplemental benefits


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

In-Network No

Inpatient hospital coverage

Out-of-Network Not Applicable
In-Network $0 copay

Outpatient hospital coverage

In-Network $0 copay

Doctor visits

Primary In-Network $0 copay
Specialist In-Network $0 copay

Preventive care

In-Network $0 copay

Coverage Area for Tribute (HMO-POS SNP)

Source: CMS.

Plans as of September 2, 2018.

Star Rating as of October 10, 2018.

Notes: Data are subject to change. All contracts for 2019 have not been finalized. For 2019, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2019 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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