2022 SummaCare Medicare Sapphire (HMO-POS)

SummaCare Medicare Sapphire (HMO-POS) H3660-029 is a 2022 Medicare Advantage Plan or Part-C by SummaCare Medicare Advantage Plans available to residents in Ohio. This plan includes additional prescription drug (Part-D) coverage. The SummaCare Medicare Sapphire (HMO-POS) has a monthly premium of $76.00 and has an in-network maximum out-of-pocket limit of $3,600 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,600 out-of-pocket. This can be a extremely nice safety net.

SummaCare Medicare Sapphire (HMO-POS) 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.

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

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2022 SummaCare Medicare Advantage Plans Medicare Advantage Plan Costs

SummaCare Medicare Sapphire (HMO-POS) Part-C Premium

SummaCare Medicare Advantage Plans charges a $28.20 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.

H3660-029 Part-D Deductible and Premium

SummaCare Medicare Sapphire (HMO-POS) has a monthly drug premium of $47.80 and a $0.00 drug deductible. This SummaCare Medicare Advantage Plans plan offers a $47.80 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 SummaCare Medicare Advantage 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 $47.80 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

SummaCare Medicare Advantage Plans Gap Coverage

In 2022 once you and your plan provider have spent $4430 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 SummaCare Medicare Advantage Plans plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The SummaCare Medicare Sapphire (HMO-POS) medicare insurance offers a $14.30 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $22.60 for 75% low income subsidy $31.00 for 50% and $39.40 for 25%.

H3660-029 Formulary or Drug Coverage

SummaCare Medicare Sapphire (HMO-POS) 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. You can see complete 2022 SummaCare Medicare Sapphire (HMO-POS) H3660-029 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$0
Tier 2	NA	$8
Tier 3	NA	$44
Tier 4	NA	$100
Tier 5	NA	33%
Tier 6	NA	$0

*Initial Coverage Phase and 30 day supply

2021 SummaCare Medicare Sapphire (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

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

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$150 copay
Diagnostic tests and procedures	$0-99 copay
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Lab services	30% coinsurance (Out-of-Network)
Lab services	$0-6 copay
Outpatient x-rays	$0-99 copay
Outpatient x-rays	30% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$20 copay per visit (Out-of-Network)
Primary	$0 copay
Specialist	$35 copay per visit
Specialist	$55 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$35 copay
Foot exams and treatment	$55 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$200 copay
$200 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$55 copay (Out-of-Network)
Hearing aids	$795 copay
Hearing exam	$55 copay (Out-of-Network)
Hearing exam	$0-15 copay

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Inpatient Hospital Coverage

$225 per day for days 1 through 6 $0 per day for days 7 through 90
25% per day for days 1 through 90 (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	30% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	30% coinsurance (Out-of-Network)
Other Part B drugs	30% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	25% per day for days 1 through 90 (Out-of-Network)
Inpatient hospital - psychiatric	$225 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$35 copay
Outpatient group therapy visit	$55 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$55 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay
Outpatient individual therapy visit	$55 copay (Out-of-Network)
Outpatient individual therapy visit	$35 copay
Outpatient individual therapy visit with a psychiatrist	$55 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay

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MOOP

$3,600 In-network

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Option

Yes, contact plan for further details

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

20% coinsurance per visit (Out-of-Network)
$250 copay per visit

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Package #1

Deductible
Monthly Premium	$28.00

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Preventive Care

$20 copay (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$55 copay (Out-of-Network)
Occupational therapy visit	$35 copay
Physical therapy and speech and language therapy visit	$55 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay

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Skilled Nursing Facility

$180 per day for days 1 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $180 per day for days 21 through 100

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$55 copay (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for SummaCare Medicare Sapphire (HMO-POS) H3660

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in SummaCare Medicare Sapphire (HMO-POS) Plans Performance

Health Plan Customer Service Rating for SummaCare Medicare Sapphire (HMO-POS)

SummaCare Medicare Sapphire (HMO-POS) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

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1-855-778-4180
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Sat 8am-8pm EST

Coverage Area for SummaCare Medicare Sapphire (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, 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 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.