Amerivantage Classic Plus (HMO-POS) H5828-005-000 is a 2021 Medicare Advantage plan with drug coverage provided by AMERIGROUP Community Care.

In terms of networks, this plan is a Local HMO. HMO plans require you to choose an in-network primary care doctor who coordinates your care with other healthcare providers in your network. With HMOs, you must generally seek care in-network. If you seek care outside of the plan’s network, the plan will only cover emergency or urgent care in most cases. Local HMOs cover only a small service area or part of the country. If you want to have costs covered out of network, you may want to look for PPOs in your county. Meanwhile, if you need a wider area of coverage, you may want to look at Regional PPO plans specifically.

When it comes to cost-sharing, you’ll want to consider both monthly costs and out-of-pocket costs. This plan has a monthly premium of $0.00, which covers both the health and drug portions of the plan.

Since this plan has a zero-dollar Premium, you can enroll at no monthly cost. Please keep in mind zero-Premium Medicare plans typically have more out-of-pocket costs than higher Premium plans. So, if you tend to spend a lot out-of-pocket in a year, make sure to check out other plans as well.

The drug plan portion of this plan provides Enhanced Alternative (EA) benefits, which are benefits that exceed the required standard.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $0.00 and an Initial Coverage Limit of $4130. This plan also notably provides extra coverage in the coverage gap phase, meaning your insurer will pay a greater share of costs for covered drugs than the standard amount required by Medicare. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5828-005-000
Plan Organization AMERIGROUP Community Care
Plan Type Local HMO
Plan Name Amerivantage Classic Plus (HMO-POS)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors Only (some exceptions)
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $4900.00
Gap Coverage Yes

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes In-Network Yes No $0 copay
Endodontics Yes In-Network Yes No $0 copay
Extractions Yes In-Network Yes No $0 copay
Non-routine services Yes In-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes No $0 copay
Restorative services Yes In-Network Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes Yes 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes Yes 40% coinsurance
Lab services - Out-of-Network Yes Yes 40% coinsurance
Outpatient x-rays - Out-of-Network Yes Yes 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $30 copay per visit
Specialist - Out-of-Network Yes Yes $50 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $30 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes Yes $50 copay
Routine foot care No In-Network Yes Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $295 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 In-Network Yes Yes $0 copay
Hearing aids Yes In-Network Yes No $0 copay
Hearing exam - Out-of-Network Yes Yes $50 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$4,900 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 40% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 40% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 40% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 40% coinsurance
Other Part B drugs - Out-of-Network Yes - 40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 40% per stay
Outpatient group therapy visit - Out-of-Network Yes Yes 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes 40% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes Yes 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes 40% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes Yes 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 40% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network Yes No $0 copay
Dental x-ray(s) Yes In-Network Yes No $0 copay
Fluoride treatment Yes In-Network Yes No $0 copay
Oral exam Yes In-Network Yes No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes Yes 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes Yes 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes In-Network No No $0 copay
Eyeglass frames Yes In-Network No No $0 copay
Eyeglass lenses Yes In-Network No No $0 copay
Eyeglasses (frames and lenses) Yes In-Network No No $0 copay
Other No - - - Not covered
Routine eye exam Yes In-Network No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Preventive dental Monthly Premium $7.00
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $31.00
Eyewear Monthly Premium $31.00
Preventive dental Monthly Premium $31.00
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $55.00
Eyewear Monthly Premium $55.00
Preventive dental Monthly Premium $55.00
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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