Rich you must be in a really screwed up area as far as Advantage plan pricing is concerned. The highest rate in my area is $180 for a elite coverage that is nearly everything 100% covered to the average of $45 a month, most with same coverages as Traditional Medicare and a few added bonuses.
This is the elite plan, sorry it's long, but just want people to see what it's like:
Important Information
Premium and Other Important Information2 General
$180.00 monthly plan premium in addition to your monthly Medicare Part B premium.
In-Network
$2,000 out-of-pocket limit. This limit includes only Medicare-covered services.
Doctor and Hospital Choice In-Network
No referral required for network doctors, specialists, and hospitals.
Inpatient Care
Inpatient Hospital Care In-Network
For Medicare-covered hospital stays:
Days 1 - 15: $100 copay per day Days 16 - 90: $0 copay per day $0 copay for additional hospital days No limit to the number of days covered by the plan each benefit period. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.
Inpatient Mental Health Care In-Network
For Medicare-covered hospital stays:
Days 1 - 15: $100 copay per day Days 16 - 90: $0 copay per day You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.
Skilled Nursing Facility (SNF) General
Authorization rules may apply.
In-Network
$0 copay for SNF services Plan covers up to 100 days each benefit period No prior hospital stay is required.
Home Health Care In-Network
$0 copay for Medicare-covered home health visits.
Hospice General
You must get care from a Medicare-certified hospice.
Outpatient Care
Doctor Office Visits General
See "Physical Exams," for more information.
In-Network
$0 copay for each primary care doctor visit for Medicare-covered benefits. $35 copay for each in-area, network urgent care Medicare-covered visit. $0 copay for each specialist doctor visit for Medicare-covered benefits.
Chiropractic Services In-Network
$0 copay for Medicare-covered chiropractic visits.
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
Podiatry Services In-Network
$0 copay for Medicare-covered podiatry benefits.
Medicare-covered podiatry benefits are for medically-necessary foot care.
Outpatient Mental Health Care In-Network
$0 copay for Medicare-covered Mental Health visits.
Outpatient Substance Abuse Care In-Network
$0 copay for Medicare-covered visits.
Outpatient Services/Surgery General
Authorization rules may apply.
In-Network
$0 copay for each Medicare-covered ambulatory surgical center visit. $0 copay for each Medicare-covered outpatient hospital facility visit.
Ambulance Services General
Authorization rules may apply.
In-Network
$0 copay for Medicare-covered ambulance benefits.
Emergency Care General
$50 copay for Medicare-covered emergency room visits.
Worldwide coverage. If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit
Urgently Needed Care General
$35 copay for Medicare-covered urgently needed care visits.
Outpatient Rehabilitation Services In-Network
$0 copay for Medicare-covered Occupational Therapy visits.
$0 copay for Medicare-covered Physical and/or Speech/Language Therapy visits.
Outpatient Medical Services and Supplies
Durable Medical Equipment General
Authorization rules may apply.
In-Network
10 % of the cost for Medicare-covered items.
Prosthetic Devices General
Authorization rules may apply.
In-Network
10 % of the cost for Medicare-covered items.
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies General
Authorization rules may apply.
In-Network
$0 copay for Diabetes self-monitoring training. $0 copay for Nutrition Therapy for Diabetes. 10 % of the cost for Diabetes supplies.
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services General
Authorization rules may apply.
In-Network
$5 copay for Medicare-covered lab services. $0 to $100 copay for Medicare-covered diagnostic procedures and tests. $0 to $100 copay for Medicare-covered X-rays. $0 to $100 copay for Medicare-covered diagnostic radiology services. 20 % of the cost for Medicare-covered therapeutic radiology services.
Preventive Services
Bone Mass Measurement In-Network
$0 copay for Medicare-covered bone mass measurement
Colorectal Screening Exams In-Network
$0 copay for Medicare-covered colorectal screenings.
Immunizations In-Network
$0 copay for Flu and Pneumonia vaccines.
$0 copay for Hepatitis B vaccine. No referral needed for Flu and pneumonia vaccines.
Mammograms (Annual Screening) In-Network
$0 copay for Medicare-covered screening mammograms.
Pap Smears and Pelvic Exams In-Network
$0 copay for Medicare-covered pap smears and pelvic exams.
Prostate Cancer Screening Exams In-Network
$0 copay for
Medicare-covered prostate cancer screening
Additional Benefits
End-Stage Renal Disease (ESRD) In-Network
20 % of the cost for renal dialysis
$0 copay for Nutrition Therapy for End-Stage Renal Disease
Prescription Drugs Drugs Covered under Medicare Part B
General
20 % of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
Drugs Covered under Medicare Part D
General
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at
www.medicare.summacare.com on the web. Different out-of-pocket costs may apply for people who
have limited incomes,
live in long term care facilities, or
have access to Indian/Tribal/Urban (Indian Health Service).
The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and the plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from SummaCare Secure Platinum (HMO-POS) for certain drugs. The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements for these drugs that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and SummaCare Secure Platinum (HMO-POS) approves the exception, you will pay Tier 3 cost-sharing for that drug.
In-Network
$0 deductible.
Initial Coverage
You pay the following until total yearly drug costs reach $2,830:
Retail Pharmacy
Tier 1 Tier 2 Tier 3 Tier 4
$3 copay for a one-month (30-day) supply of drugs in this tier
$35 copay for a one-month (30-day) supply of drugs in this tier
$70 copay for a one-month (30-day) supply of drugs in this tier
33 % coinsurance for a one-month (30-day) supply of drugs in this tier
$9 copay for a three-month (90-day) supply of drugs in this tier
$105 copay for a three-month (90-day) supply of drugs in this tier
$210 copay for a three-month (90-day) supply of drugs in this tier
33 % coinsurance for a three-month (90-day) supply of drugs in this tier
Long Term Care Pharmacy
Tier 1 Tier 2 Tier 3 Tier 4
$3 copay for a one-month (31-day) supply of drugs in this tier
$35 copay for a one-month (31-day) supply of drugs in this tier
$70 copay for a one-month (31-day) supply of drugs in this tier
33 % coinsurance for a one-month (31-day) supply of drugs in this tier
Mail Order
Tier 1 Tier 2 Tier 3 Tier 4
$7.50 copay for a three-month (90-day) supply of drugs in this tier
$87.50 copay for a three-month (90-day) supply of drugs in this tier
$210 copay for a three-month (90-day) supply of drugs in this tier
33 % coinsurance for a three-month (90-day) supply of drugs in this tier
Coverage Gap
The plan covers all generics (100 % of formulary generic drugs) through the coverage gap. You pay the following:
Retail Pharmacy
Tier 1
$3 copay for a one-month (30-day) supply of all drugs covered in this tier
$9 copay for a three-month (90-day) supply of all drugs covered in this tier
Long Term Care Pharmacy
Tier 1
$3 copay for a one-month (31-day) supply of all drugs covered in this tier
Mail Order
Tier 1
$7.50 copay for a three-month (90-day) supply of all drugs covered in this tier For all other covered drugs, after your total yearly drug costs reach $2,830, you pay 100 % until your yearly out-of-pocket drug costs reach $4,550.
Catastrophic Coverage
After your yearly out-of-pocket drug costs reach $ 4,550, you pay the greater of:
A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or
5 % coinsurance.
Out-of-Network
Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from SummaCare Secure Platinum (HMO-POS).
Out-of-Network Initial Coverage
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,830:
Out-of-Network Pharmacy
Tier 1 Tier 2 Tier 3 Tier 4
$3 copay for a one-month (30-day) supply of drugs in this tier
$35 copay for a one-month (30-day) supply of drugs in this tier
$70 copay for a one-month (30-day) supply of drugs in this tier
33 % coinsurance for a one-month (30-day) supply of drugs in this tier
Out-of-Network Coverage Gap
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: Tier 1 Tier 2 Tier 3 Tier 4
$3 copay for a one-month (30-day) supply of all drugs covered in this tier
After your total yearly drug costs reach $2,830, you pay 100 % of the pharmacy's full charge for drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed by SummaCare Secure Platinum (HMO-POS) for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to SummaCare Secure Platinum (HMO-POS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year.
After your total yearly drug costs reach $2,830, you pay 100 % of the pharmacy's full charge for drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed by SummaCare Secure Platinum (HMO-POS) for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to SummaCare Secure Platinum (HMO-POS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year.
After your total yearly drug costs reach $2,830, you pay 100 % of the pharmacy's full charge for drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed by SummaCare Secure Platinum (HMO-POS) for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to SummaCare Secure Platinum (HMO-POS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year.
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the following:
A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or
5 % coinsurance.
Dental Services In-Network
$0 copay for Medicare-covered dental benefits
In general, preventive dental benefits (such as cleaning) not covered.
Hearing Services In-Network
Hearing aids not covered.
$0 copay for Medicare-covered diagnostic hearing exams
up to 1 routine hearing test(s) every year
Vision Services In-Network
$0 copay for diagnosis and treatment for diseases and conditions of the eye
and up to 1 routine eye exam(s) every year $0 copay for
one pair of eyeglasses or contact lenses after cataract surgery
Physical Exams In-Network
$0 copay for routine exams.
Limited to 1 exam(s) every year.
Health/Wellness Education In-Network
The plan covers the following health/wellness education benefits:
Written health education materials, including Newsletters
Nutritional Training
Nutritional benefit
Additional Smoking Cessation
Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session.
Transportation In-Network
This plan does not cover routine transportation.
Acupuncture In-Network
This plan does not cover Acupuncture.
Point of Service General
Authorization rules may apply.
Out-of-Network
Point of Service coverage is available for the following benefits:
Inpatient Hospital Care
Inpatient Mental Health Care
Skilled Nursing Facility (SNF)
Home Health Care
Doctor Office Visits
Chiropractic Services
Podiatry Services
Outpatient Mental Health Care
Outpatient Substance Abuse Care
Outpatient Services/Surgery
Ambulance Services
Outpatient Rehabilitation Services
Durable Medical Equipment
Prosthetic Devices
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
Bone Mass Measurement
Colorectal Screening Exam
Immunizations
Mammograms (Annual Screenings)
Pap Smears and Pelvic Exams
Prostate Cancer Screening Exams
Dental Services
Hearing Services
Vision Services
Physical Exams
Comprehensive Outpatient Rehabilitation Facility (CORF)
Partial Hospitalization
Other Health Care Professional Services
Diagnostic Radiological Services
Therapeutic Radiological Services
Outpatient X-Rays
Cardiac Rehabilitation Services
Outpatient Blood
Nutrition Therapy for Diabetes and Renal Disease
For hospital stays: Days 1 - 90: 15 % of the cost per day For Inpatient Psychiatric Hospital stays: 15 % of the cost per day for day(s) 1 - 90 For each SNF stay: Days 1 - 100: $50 copay per SNF day 20 % of the cost for
Home Health Care
Durable Medical Equipment
Prosthetic Devices
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
Diagnostic Radiological Services
Therapeutic Radiological Services
Outpatient X-Rays
$15 copay for
Doctor Office Visits
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
Bone Mass Measurement
Colorectal Screening Exam
Immunizations
Mammograms (Annual Screenings)
Pap Smears and Pelvic Exams
Prostate Cancer Screening Exams
Physical Exams
Nutrition Therapy for Diabetes and Renal Disease
$35 copay for
Doctor Office Visits
Chiropractic Services
Podiatry Services
Outpatient Mental Health Care
Outpatient Substance Abuse Care
Outpatient Rehabilitation Services
Dental Services
Hearing Services
Vision Services
CORF
Partial Hospitalization
Cardiac Rehabilitation Services
$150 copay for
Outpatient Services/Surgery
Ambulance Services
