Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H9877-001-000
Plan Organization Virginia Premier
Plan Type Local HMO
Plan Name Virginia Premier Advantage Elite (HMO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 3 Stars
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part D Basic Premium $27.90
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $27.90
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.00
Monthly Part D Premium 50% Assistance $14.00
Monthly Part D Premium 25% Assistance $20.90
Part D Drug Deductible $435.00
Annual Drug Deductible $435
Part D Initial Coverage Limit $4020
Part D Catastrophic Coverage Threshold $6350
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Extractions Yes - No No $0 copay
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services Yes - No No $0 copay
Endodontics No - - - Not covered
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care Yes - Yes No $0
Foot exams and treatment - - Yes No $0 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No No $0
Hearing exam - - No No $0 copay
Hearing aids Yes - No Yes $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,400 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - $0 copay
Prosthetics (e.g., braces, artificial limbs) - - Yes - $0 copay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient individual therapy visit - - Yes No $0 copay
Outpatient group therapy visit - - Yes No $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes No $0 copay
Inpatient hospital - psychiatric - - Yes No $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $0 copay
Outpatient x-rays - - Yes No $0 copay
Lab services - - Yes No $0 copay
Diagnostic tests and procedures - - Yes No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $0 copay
Emergency - - - - $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - $0 copay
Other Part B drugs - - Yes - $0 copay
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Fluoride treatment No - - - Not covered
Dental x-ray(s) Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No $0 copay
Physical therapy and speech and language therapy visit - - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Eyeglass frames Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Routine eye exam No - - - Not covered
Upgrades - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Accomack County, Virginia, Albemarle County, Virginia, Alexandria City County, Virginia, Alleghany County, Virginia, Amelia County, Virginia, Amherst County, Virginia, Appomattox County, Virginia, Arlington County, Virginia, Augusta County, Virginia, Bath County, Virginia, Bedford County, Virginia, Bland County, Virginia, Botetourt County, Virginia, Bristol City County, Virginia, Brunswick County, Virginia, Buchanan County, Virginia, Buckingham County, Virginia, Buena Vista City County, Virginia, Campbell County, Virginia, Caroline County, Virginia, Carroll County, Virginia, Charles City County, Virginia, Charlotte County, Virginia, Charlottesville City County, Virginia, Chesapeake City County, Virginia, Chesterfield County, Virginia, Clarke County, Virginia, Colonial Heights City County, Virginia, Covington City County, Virginia, Craig County, Virginia, Culpeper County, Virginia, Cumberland County, Virginia, Danville City County, Virginia, Dickenson County, Virginia, Dinwiddie County, Virginia, Emporia City County, Virginia, Essex County, Virginia, Fairfax City County, Virginia, Fairfax County, Virginia, Falls Church City County, Virginia, Fauquier County, Virginia, Floyd County, Virginia, Fluvanna County, Virginia, Franklin City County, Virginia, Franklin County, Virginia, Frederick County, Virginia, Fredericksburg City County, Virginia, Galax City County, Virginia, Giles County, Virginia, Gloucester County, Virginia, Goochland County, Virginia, Grayson County, Virginia, Greene County, Virginia, Greensville County, Virginia, Halifax County, Virginia, Hampton City County, Virginia, Hanover County, Virginia, Harrisonburg City County, Virginia, Henrico County, Virginia, Henry County, Virginia, Highland County, Virginia, Hopewell City County, Virginia, Isle Of Wight County, Virginia, James City County, Virginia, King And Queen County, Virginia, King George County, Virginia, King William County, Virginia, Lancaster County, Virginia, Lee County, Virginia, Lexington City County, Virginia, Loudoun County, Virginia, Louisa County, Virginia, Lunenburg County, Virginia, Lynchburg City County, Virginia, Madison County, Virginia, Manassas City County, Virginia, Manassas Park City County, Virginia, Martinsville City County, Virginia, Mathews County, Virginia, Mecklenburg County, Virginia, Middlesex County, Virginia, Montgomery County, Virginia, Nelson County, Virginia, New Kent County, Virginia, Newport News City County, Virginia, Norfolk City County, Virginia, Northampton County, Virginia, Northumberland County, Virginia, Norton City County, Virginia, Nottoway County, Virginia, Orange County, Virginia, Page County, Virginia, Patrick County, Virginia, Petersburg City County, Virginia, Pittsylvania County, Virginia, Poquoson City County, Virginia, Portsmouth City County, Virginia, Powhatan County, Virginia, Prince Edward County, Virginia, Prince George County, Virginia, Prince William County, Virginia, Pulaski County, Virginia, Radford County, Virginia, Rappahannock County, Virginia, Richmond City County, Virginia, Richmond County, Virginia, Roanoke City County, Virginia, Roanoke County, Virginia, Rockbridge County, Virginia, Rockingham County, Virginia, Russell County, Virginia, Salem County, Virginia, Scott County, Virginia, Shenandoah County, Virginia, Smyth County, Virginia, Southampton County, Virginia, Spotsylvania County, Virginia, Stafford County, Virginia, Staunton City County, Virginia, Suffolk City County, Virginia, Surry County, Virginia, Sussex County, Virginia, Tazewell County, Virginia, Virginia Beach City County, Virginia, Warren County, Virginia, Washington County, Virginia, Waynesboro City County, Virginia, Westmoreland County, Virginia, Williamsburg City County, Virginia, Winchester City County, Virginia, Wise County, Virginia, Wythe County, Virginia, York County, Virginia

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