Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3672-020-000
Plan Organization The Health Plan
Plan Type Local HMO
Plan Name The Health Plan SecureCare - Option II (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4
Plan Cost Sharing
Premium $65.00
Total Premium (Includes Part B) $200.50
Monthly Part C Premium $30.70
Monthly Part D Basic Premium $34.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $34.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $8.60
Monthly Part D Premium 50% Assistance $17.20
Monthly Part D Premium 25% Assistance $25.70
Part D Drug Deductible $100.00
Annual Drug Deductible $100.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage No

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 No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes Yes $0-150 copay
Diagnostic tests and procedures - - No No $50 copay
Lab services - - No No $0 copay
Outpatient x-rays - - Yes Yes $50 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $10 copay per visit
Specialist - - Yes Yes $45 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 - - - - $45 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes Yes $45 copay
Routine foot care Yes - Yes Yes $45 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $250 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 No - - - Not covered
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - No No $45 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $250 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $7.50 copay or 0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $250 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - - Yes Yes $40 copay
Outpatient group therapy visit with a psychiatrist - - Yes Yes $40 copay
Outpatient individual therapy visit - - Yes Yes $40 copay
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $40 copay
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
- - Yes Yes $0-250 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes Yes $40 copay
Physical therapy and speech and language therapy visit - - Yes Yes $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 per day for days 1 through 20$178 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes - No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $23.60
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
Plan Available in these Counties
Barbour County, West Virginia, Belmont County, Ohio, Berkeley County, West Virginia, Braxton County, West Virginia, Brooke County, West Virginia, Cabell County, West Virginia, Calhoun County, West Virginia, Doddridge County, West Virginia, Gilmer County, West Virginia, Grant County, West Virginia, Greenbrier County, West Virginia, Guernsey County, Ohio, Hampshire County, West Virginia, Hancock County, West Virginia, Hardy County, West Virginia, Harrison County, Ohio, Harrison County, West Virginia, Jefferson County, Ohio, Jefferson County, West Virginia, Lewis County, West Virginia, Lincoln County, West Virginia, Logan County, West Virginia, Marion County, West Virginia, Marshall County, West Virginia, Mason County, West Virginia, Mcdowell County, West Virginia, Mercer County, West Virginia, Mineral County, West Virginia, Mingo County, West Virginia, Monongalia County, West Virginia, Monroe County, Ohio, Monroe County, West Virginia, Morgan County, West Virginia, Muskingum County, Ohio, Nicholas County, West Virginia, Noble County, Ohio, Ohio County, West Virginia, Pendleton County, West Virginia, Pleasants County, West Virginia, Pocahontas County, West Virginia, Preston County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Summers County, West Virginia, Taylor County, West Virginia, Tucker County, West Virginia, Tyler County, West Virginia, Upshur County, West Virginia, Washington County, Ohio, Wayne County, West Virginia, Webster County, West Virginia, Wetzel County, West Virginia, Wirt County, West Virginia, Wood County, West Virginia, Wyoming County, West Virginia

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