2021 Amerivantage Classic Plus (HMO) H8849-008 By Amerigroup Insurance Company.

Summary of Benefits for
2021 Amerivantage Classic Plus (HMO)


Amerivantage Classic Plus (HMO) H8849-008 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Amerigroup Insurance Company available to residents in Texas. This plan includes additional Medicare prescription drug (Part-D) coverage. The Amerivantage Classic Plus (HMO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $5,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,500 out of pocket. This can be a extremely nice safety net.

Amerivantage Classic Plus (HMO) 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 require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.

Amerigroup Insurance Company works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Amerivantage Classic Plus (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Amerigroup Insurance Company 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 Amerigroup Insurance Company 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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2021 Amerigroup Insurance Company Medicare Advantage Plan Costs

Name:
Amerivantage Classic Plus (HMO)
Plan ID:
H8849-008
Provider:Amerigroup Insurance Company
Year:2021
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium: $0
MOOP: $5,500
Part D (Drug) Premium: $0
Part D Supplemental Premium $0
Total Part D Premium: $0
Drug Deductible: $0
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H8849-009




Amerivantage Classic Plus (HMO) Part-C Premium

Amerigroup Insurance Company plan charges a $0 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.



H8849-008 Part-D Deductible and Premium

Amerivantage Classic Plus (HMO) has a monthly drug premium of $0 and a $0 drug deductible. This Amerigroup Insurance Company plan offers a $0 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 this Premium covers any enhanced plan benefits offered by Amerigroup Insurance Company 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 . 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.



Amerigroup Insurance Company Gap Coverage

In 2021 once you and your plan provider have spent $4130 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 prescription drugs unless your plan offers additional coverage. This Amerigroup Insurance Company plan does offer additional coverage through the gap.



H8849-008 Formulary or Drug Coverage

Amerivantage Classic Plus (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $5 $10
Tier 2 $12 $17
Tier 3 $42 $47
Tier 4 $95 $100
Tier 5 33% 33%
Tier 6 $0 $0
*Initial Coverage Phase and 30 day supply







2021 Amerivantage Classic Plus (HMO) Summary of Benefits




Additional Benefits


No



Comprehensive Dental


Diagnostic services $0 copay
Endodontics $0 copay
Extractions $0 copay
Non-routine services $0 copay
Periodontics $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services $0 copay



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $125-250 copay
Diagnostic tests and procedures $0-150 copay
Lab services $0 copay
Outpatient x-rays $35-60 copay



Doctor Visits


Primary $0 copay
Specialist $35 copay per visit



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $35 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $0-35 copay
Routine foot care $0 copay



Ground Ambulance


$250 copay



Hearing


Fitting/evaluation $0 copay
Hearing aids $0 copay
Hearing exam $35 copay



Inpatient Hospital Coverage


$275 per day for days 1 through 5
$0 per day for days 6 through 90



Medical Equipment/Supplies


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



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $265 per day for days 1 through 7
$0 per day for days 8 through 90
Outpatient group therapy visit $35 copay
Outpatient group therapy visit with a psychiatrist $35 copay
Outpatient individual therapy visit $35 copay
Outpatient individual therapy visit with a psychiatrist $35 copay



MOOP


$6,700 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$0-255 copay per visit



Preventive Care


$0 copay



Preventive Dental


Cleaning $0 copay
Dental x-ray(s) $0 copay
Fluoride treatment $0 copay
Oral exam $0 copay



Rehabilitation Services


Occupational therapy visit $35 copay
Physical therapy and speech and language therapy visit $35 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$140 per day for days 21 through 100



Transportation


$0 copay



Vision


Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass lenses $0 copay
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $0 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered





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1-855-778-4180
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Sun 9am-6pm EST




Coverage Area for Amerivantage Classic Plus (HMO)

(Click county to compare all available Advantage plans)

State: Texas
County:


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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, 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 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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