Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1587-003-000
Plan Organization Tribute Health Plans
Plan Type Local HMO
Plan Name Tribute Select (HMO-POS I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors Only (some exceptions)
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating 4
Plan Cost Sharing
Premium $24.90
Total Premium (Includes Part B) $160.40
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $24.90
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $24.90
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.20
Monthly Part D Premium 50% Assistance $12.40
Monthly Part D Premium 25% Assistance $18.70
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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) - Out-of-Network No No 20% coinsurance
Diagnostic tests and procedures - Out-of-Network No No 20% coinsurance
Lab services - Out-of-Network No No 20% coinsurance
Outpatient x-rays - Out-of-Network No No 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 20% coinsurance per visit
Specialist - Out-of-Network No No 20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - 20% coinsurance per visit (always covered)
Urgent care - - - - 20% coinsurance per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 20% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Coming soon
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 - Out-of-Network No No 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Coming soon
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 - Out-of-Network No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network No - 20% coinsurance
Other Part B drugs - Out-of-Network No - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No Coming soon
Outpatient group therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 20% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
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 No No 20% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 20% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 20% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 20% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network No No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam No - - - Not covered
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
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
Arkansas County, Arkansas, Ashley County, Arkansas, Baxter County, Arkansas, Benton County, Arkansas, Boone County, Arkansas, Bradley County, Arkansas, Calhoun County, Arkansas, Carroll County, Arkansas, Chicot County, Arkansas, Clark County, Arkansas, Clay County, Arkansas, Cleburne County, Arkansas, Cleveland County, Arkansas, Columbia County, Arkansas, Conway County, Arkansas, Craighead County, Arkansas, Crawford County, Arkansas, Crittenden County, Arkansas, Cross County, Arkansas, Dallas County, Arkansas, Desha County, Arkansas, Drew County, Arkansas, Faulkner County, Arkansas, Franklin County, Arkansas, Fulton County, Arkansas, Garland County, Arkansas, Grant County, Arkansas, Greene County, Arkansas, Hempstead County, Arkansas, Hot Spring County, Arkansas, Howard County, Arkansas, Independence County, Arkansas, Izard County, Arkansas, Jackson County, Arkansas, Jefferson County, Arkansas, Johnson County, Arkansas, Lafayette County, Arkansas, Lawrence County, Arkansas, Lee County, Arkansas, Lincoln County, Arkansas, Little River County, Arkansas, Logan County, Arkansas, Lonoke County, Arkansas, Madison County, Arkansas, Marion County, Arkansas, Miller County, Arkansas, Mississippi County, Arkansas, Monroe County, Arkansas, Montgomery County, Arkansas, Nevada County, Arkansas, Newton County, Arkansas, Ouachita County, Arkansas, Perry County, Arkansas, Phillips County, Arkansas, Pike County, Arkansas, Poinsett County, Arkansas, Polk County, Arkansas, Pope County, Arkansas, Prairie County, Arkansas, Pulaski County, Arkansas, Randolph County, Arkansas, Saint Francis County, Arkansas, Saline County, Arkansas, Scott County, Arkansas, Searcy County, Arkansas, Sebastian County, Arkansas, Sevier County, Arkansas, Sharp County, Arkansas, Stone County, Arkansas, Union County, Arkansas, Van Buren County, Arkansas, Washington County, Arkansas, White County, Arkansas, Woodruff County, Arkansas, Yell County, Arkansas

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