-
Summary of Benefts 2020
Virginia Premier Advantage Gold (HMO) H9877-002 Virginia Premier
Advantage Platinum (HMO) H9877-003
This Summary of Benefts includes service areas in Central
Virginia and Eastern Virginia
H9877_0719-SBGP20-800073_M F&U Date - 08/26/2019
-
2020 Central Virginia Service Area
Virginia Premier Advantage Gold and Advantage Platinum
Service Area – 26 cities/counties
Amelia, Brunswick, Caroline, Charles City, Charlotte,
Chesterfeld, Colonial Heights City, Cumberland, Dinwiddie,
Goochland, Halifax, Hanover, Henrico, Hopewell City, King and
Queen, King William, Louisa, Lunenburg, Mecklenburg, New Kent,
Nottoway, Petersburg City, Powhatan, Prince George, Richmond City,
and Sussex
2020 Eastern Virginia Service Area
Virginia Premier Advantage Gold and Advantage Platinum
Service Area – 21 cities/counties
Chesapeake City, Emporia City, Essex, Franklin City, Gloucester,
Greensville, Hampton City, Isle of Wight, James City, Mathews,
Middlesex, Newport News City, Norfolk City, Poquoson City,
Portsmouth City, Southampton, Suffolk City, Surry, Virginia Beach
City, Williamsburg City, and York
1
-
Let’s talk about Virginia Premier Advantage Gold (HMO) and
Advantage Platinum (HMO) Plans (H9877-002 and H9877-003) This
summary will let you fnd out more about our Gold and Platinum plans
including the medical and drug services they cover.
Virginia Premier Advantage Gold and Advantage Platinum are
Medicare Advantage HMO plans with a Medicare contract. Enrollment
in the plans depends on contract renewal.
The beneft information in this document is a summary of what we
cover and what you pay. It does not list every service we cover or
every limitation or exclusion from our plan. To get a complete list
of services we cover, please call our Member Services department to
request a copy of the Evidence of Coverage or visit us online at
VirginiaPremier.com.
To be eligible for our HMO plans:
To join Virginia Premier Medicare Advantage Gold (HMO) or
Advantage Platinum (HMO), you must be entitled to Medicare Part A,
be enrolled in Medicare Part B and live in the service area of our
plans. Please see the map of our service area on the inside cover
of this booklet.
Note: As a member you must select an in-network doctor to act as
your Primary Care Provider (PCP). However, you can see one of our
Specialist doctors without a referral from your PCP. We do
encourage all of our members to seek Specialist referrals with
their PCP.
How to contact us:
If you are not a member of our plan, please contact us toll-free
at 1-833-280-1216 (TTY: 711) for more information. You will be
connected with a licensed Medicare Beneft Advisor.
If you are a member of our plan, please call us toll-free at
1-877-739-1370 (TTY: 711) to speak to a Medicare Benefts
Representative. Our representatives are available 7 days a week, 8
am to 8 pm October 1 through March 31. From April 1 through
September 30, they are available Monday through Friday 8 am to 8
pm. On certain holidays and weekends from April 1 through September
30, you call will be handled by our automated phone system.
Visit our web site at VirginiaPremier.com.
What doctors and hospitals you can use:
We have a network of doctors, hospitals, and other providers. If
you use providers that are not in our network, the plan may not pay
for these services.
You can see our plan’s provider directory and view our
prescription drug formulary on our website at
VirginiaPremier.com.
This document is available in other formats such as large print
and audio.
2
http://medicare.virginiapremier.comhttp://virginiapremier.comhttp://virginiapremier.com
-
To fnd out more about the coverage and costs of Original
Medicare, look in the current “Medicare & You” handbook. View
it online at medicare.gov or get a copy by calling 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should
call 1-877-486-2048.
Virginia Premier is an HMO and HMO SNP organization with a
Medicare contract. Enrollment in Virginia Premier depends on
contract renewal. This information is not a complete description of
benefts. Contact the plan for more information. Virginia Premier
Health Plan, Inc. is a fully-owned subsidiary of VCU Health. Other
physicians and providers are available in our network.
Monthly Premium, Deductible and Out-of-Pocket Limits
Premiums and Benefts Medicare Advantage Gold (HMO)
Medicare Advantage Platinum (HMO)
Monthly Premium $0 $29
Medical Deductible $0 $0
Pharmacy (PART D) Prescription Drug Deductible
$250 for Tier 3, Tier 4 and Tier 5 $0 for Tier 1 and Tier 2
$5,900 annually. After you reach this amount through co-pays,
coinsurance and other medical services we will pay the full cost of
covered services for the rest of the year.
$100 for Tier 3, Tier 4 and Tier 5 $0 for Tier 1 and Tier 2
$5,900 annually. After you reach this amount through co-pays,
coinsurance and other medical services we will pay the full cost of
covered services for the rest of the year.
Out-of-pocket Maximum (Does not include prescription drugs)
How can we charge a $0 or very low premium? Virginia Premier is
reimbursed each month from the Centers for Medicare & Medicaid
Services (CMS) for our covered members. We become your insurer of
Medicare benefts in place of CMS and Original Medicare.
Covered Medical and Hospital Benefts
Inpatient Hospital1 $300 co-pay for days 1 through 5 $0 co-pay
for days 6 and beyond
$250 co-pay for days 1 through 5 $0 co-pay for days 6 and
beyond
Outpatient Hospital1 Outpatient Hospital: $325 co-pay Ambulatory
Surgical Center: $275 co-pay
Outpatient Hospital: $300 co-pay Ambulatory Surgical Center:
$250 co-pay
Doctor Visits Primary care provider: $0 co-pay Specialists: $45
co-pay
Primary care provider: $0 co-pay Specialists: $35 co-pay
Preventive Care Screenings
Our plan covers many preventive services at $0 co-pay when you
get services with an in-network provider.
Our plan covers many preventive services at $0 co-pay when you
get services with an in-network provider.
Annual Physical Exam* $0 co-pay $0 co-pay
* If you receive either an annual wellness exam or annual
physical exam you will receive a$25 incentive just for getting the
exam
3
https://medicare.gov
-
Hearing Services
Medicare-Covered Exams to Diagnose and Treat Hearing and Balance
Issues
You pay $45 co-pay You pay $35 co-pay
Routine Hearing Exam You pay $0 for one routine hearing exam and
ftting annually
You pay $0 for one routine hearing exam and ftting annually
Hearing Aid Allowance Up to $750 every 3 years for a hearing
aid. Major discounts with our hearing aid supplier. Extended
warranty and 1 year of batteries.
Up to $1,000 every 3 years for a hearing aid. Major discounts
with our hearing aid supplier. Extended warranty and 1 year of
batteries.
Outpatient Care and Services
Diagnostic Services, Labs and Imaging1Note: Cost sharing will
vary depending on the service and where it is given
• Therapeutic radiology services:$60
• X-ray services: $45
• Diagnostic radiology (CT, MRI,etc.): $275-$325 depending
onservice location.
• Labs and testing: $15
• Therapeutic radiology services:$50
• X-ray services: $35
• Diagnostic radiology (CT, MRI,etc.): $250-$300 depending
onservice location
• Labs and testing: $0
Emergency Care
Beneft Category Medicare Advantage Gold (HMO)
Medicare Advantage Platinum (HMO)
Emergency Room $90 per visit Note: If you are admitted to the
hospital within 3 days, you do not have to pay your share of the
cost for the emergency room
$90 per visit Note: If you are admitted to the hospital within 3
days, you do not have to pay your share of the cost for the
emergency room
Worldwide Emergency Care
Up to $50,000 per year Up to $50,000 per year
Dental
Routine Dental Services You pay $0 for 2 cleanings, 2 fuoride
treatments, 2 exams, and 1 bitewing and 1 panoramic X-ray every 3
years
You pay $0 for 2 cleanings, 2 fuoride treatments, 2 exams, and 1
bitewing and 1 panoramic X-ray every 3 years
Comprehensive Dental Services
50% coinsurance for fllings, extractions, crowns, implants and
bridges up to $1,000 per year
50% coinsurance for fllings, extractions, crowns, implants and
bridges up to $1,000 per year
4
-
Vision
Beneft Category
Medicare-Covered Vision Services
Routine Vision Care
Eyewear
Mental Health Services
Inpatient Stays1
Outpatient Group Therapy/ You pay $40 co-pay You pay $30 co-pay
Individual Therapy Visit1
You pay $300 per day for days 1-5 You pay $0 days 6-150
You pay $250 per day for days 1-5 You pay $0 days 6-150
Rehabilitative Services
Medicare Advantage Gold (HMO)
Medicare Advantage Platinum (HMO)
You pay $45 co-pay You pay $35 co-pay
You pay $0 for 1 exam annually You pay $0 for 1 exam
annually
$150 allowance toward glasses/ $200 allowance toward glasses/
contacts annually contacts annually
Cardiac Rehabilitation Services1
Intensive Cardiac Rehabilitation Services1
Pulmonary Rehabilitation Services1
Supervised Exercise Therapy (SET) for Symptomatic Peripheral
Artery Disease (PAD)1
Skilled Nursing Facility (SNF)1
Physical Therapy/ Occupational Therapy/ Speech Language
Pathology1
Medicare-covered $50 co-pay Medicare-covered $50 co-pay
Medicare-covered $100 co-pay Medicare-covered $100 co-pay
Medicare-covered $30 co-pay Medicare-covered $30 co-pay
Medicare-covered $30 co-pay Medicare-covered $30 co-pay
You pay $0 days 1-20 You pay $160 per day for days 21-100
You pay $0 days 1-20 You pay $140 per day for days 21-100
You pay $40 co-pay You pay $35 co-pay
5
-
Additional Benefts
Beneft Category Medicare Advantage Gold (HMO)
Medicare Advantage Platinum (HMO)
Ambulance Services -Ground2
You pay $275 co-pay You pay $250 co-pay
Ambulance Services - Air2 20% coinsurance 20% coinsurance
Transportation1 $0 co-pay for 6 one-way trips or 3 round trips
per year
$0 co-pay for 4 one-way trips or 2 round trips per year
Medicare Part B Drugs1 You pay 20% of the cost for chemotherapy
drugs You pay 20% of the cost for other Part B drugs
You pay 20% of the cost for chemotherapy drugs You pay 20% of
the cost for other Part B drugs
Footcare (Podiatry Services) Medicare-Covered Services1
You pay $45 co-pay You pay $35 co-pay
Routine Footcare You pay $20 co-pay per visit, 4 visits
annually
You pay $20 co-pay per visit, 8 visits annually
Durable Medical Equipment and Supplies1
You pay 20% of the cost You pay 20% of the cost
Fitness Beneft Fitness center membership You pay nothing at
participating facilities
Fitness center membership You pay nothing at participating
facilities
Chiropractor Routine care not covered $20 co-pay for
Medicare-covered services
$0 co-pay for 6 routine care visits annually $20 co-pay for
Medicare-covered services
Over-the-Counter (OTC) Drug Beneft
$50 mail order allowance per quarter (does not carry over)
Meals ordered by Physician or Plan Care Coordinator after
discharge from inpatient or skilled nursing facility stay. Member
receive up to 28 meals (2 per day) for qualifed discharge.
$60 mail order allowance per quarter (does not carry over)
Meals ordered by Physician or Plan Care Coordinator after
discharge from inpatient or skilled nursing facility stay. Member
receive up to 28 meals (2 per day) for qualifed discharge.
Meal Beneft
1 You do not need a referral to receive covered services from
providers. However, certain procedures, services and drugs marked
with a 1 may need approval in advance from your plan. This is
called “prior authorization.” Please contact your PCP or refer to
the Evidence of Coverage (EOC) for services that require a prior
authorization from our plan. The provider/pharmacy network may
change at any time. You will receive notice when necessary.
2 Authorization required for non-emergency services
6
-
Outpatient Prescription Drugs
Beneft Category Medicare Advantage Gold (HMO)
Medicare Advantage Platinum (HMO)
Pharmacy Deductible $250 annual deductible for Tier 3, Tier 4,
and Tier 5 $0 for Tier 1 and Tier 2
$100 annual deductible for Tier 3, Tier 4, and Tier 5 $0 for
Tier 1 and Tier 2
Initial Coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach
$4,020. Total yearly drug costs are the total drug costs paid by
both you and our plan.
Outpatient Prescription Drugs – Initial Coverage
Advantage Gold Plan Retail Rx 31-day supply Retail Rx 90-day
supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay
$15
Tier 3: Preferred Brand You pay $47 You pay $141 You pay
$117.50
Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay
$250
Tier 5: Specialty Tier You pay 28% Not offered Not offered
Advantage Platinum Plan Retail Rx 31-day supply Retail Rx 90-day
supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay
$12
Tier 3: Preferred Brand You pay $47 You pay $141 You pay
$117.50
Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay
$250
Tier 5: Specialty Tier You pay 31% Not offered Not offered
Note: Specialty drugs are limited to a 31-day supply. Cost
sharing may change if you qualify for "Extra Help." To fnd out if
you qualify, please contact the Social Security Offce at
1-800-772-1213, Monday - Friday 7 am to 7 pm. TTY users should call
1-800-325-0778. For more information on the additional
pharmacy-specifc cost sharing and the phases of the beneft, please
call us or access our “Evidence of Coverage” online.
If you reside in a long-term care facility, you pay the same as
a standard retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay
more than you pay at an in-network facility.
7
-
Coverage Gap
Most Medicare drug plans have a coverage gap (also called the
“donut hole”.) This means that there’s a temporary change in what
you will pay for your drugs. The coverage gap begins after the
total yearly drug costs (including what our plan has paid and what
you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s
costs for covered brand name drugs until your costs total $6,350
which is the end of the coverage gap. Not everyone will enter the
coverage gap.
Coverage Gap
Advantage Gold Plan Retail Rx 31-day supply Retail Rx 90-day
supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay
$15
Advantage Platinum Plan Retail Rx 31-day supply Retail Rx 90-day
supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay
$12
For all other formulary drugs, after you enter the coverage gap,
you pay 25% of the plan's cost for covered brand name drugs, until
your costs total $6,350, which is the end of the coverage gap.
Catastrophic Phase
After your yearly out-of-pocket drug costs (including drugs
purchased through your retail pharmacy and through mail order)
reach $6,350 you pay $3.60 co-pay for those generic or preferred
generic with a retail price under $72 and 5% of the cost for those
with a retail price greater than $72. For brand-name drugs you pay
$8.95 co-pay for those drugs with a retail price under $179 and 5%
coinsurance for those with a retail price over $179.
Find Your Doctors, Hospitals, Pharmacies and Research Our Drug
Formulary Providers/Pharmacies
You can easily fnd a list of our providers online. Visit
VirginiaPremier.com to fnd the most up-to-date list of our
providers, including doctors, hospitals, urgent care centers and
pharmacies in our network. You can always call one of our Medicare
Member Services Representatives at 1-877-739-1370 (TTY: 711) to ask
about providers and facilities in our network. From October 1 to
March 31, we are open daily from 8 am to 8 pm, 7 days a week. From
April 1 through September 30, we are open Monday through Friday, 8
am to 8 pm. On certain holidays and weekends from April 1 through
September 30, your call will be handled by our automated phone
system.
Formulary
You can check our full formulary online at VirginiaPremier.com
or call one of our Medicare Member Services Representatives at the
number above. Medicare Beneft Advisors who are licensed sales
representatives are also available toll free at 1-833-280-1216.
8
http://virginiapremier.comhttp://virginiapremier.com
-
H9877_0817-NND-600001 AI 08/25/2017
Notice of Non-Discrimination
Virginia Premier Health Plan, Inc. (Virginia Premier) complies
with applicable Federal civil rights
laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex.
Virginia Premier does not exclude people or treat them
differently because of race, color,
national origin, age, disability, or sex.
Virginia Premier:
Provides free aids and services to people with disabilities to
communicate
effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio,
accessible
electronic formats, other formats)
Provides free language services to people whose primary language
is not
English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Member Services at
1-877-739-1370, TTY: 711.
If you believe that Virginia Premier has failed to provide these
services or discriminated in
another way on the basis of race, color, national origin, age,
disability, or sex, you can file a
grievance with:
Virginia Premier
Attn: Grievances & Appeals Manager
P.O. Box 5244
Richmond, VA 23220
1-877-739-1370, TTY: 711
Fax: 800-289-4970
[email protected]
You can file a grievance in person or by mail, fax, or email. If
you need help filing a
grievance, the Grievances & Appeals Manager is available to
help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human
Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
9
mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
-
H9877_0817-MLI-500009 Accepted 08/20/2017
Multi-Language Insert Multi-Language Interpreter Services
ATTENTION: If you speak English, language assistance services,
free of charge, are available to you. Call 1-877-739-1370 (TTY:
711).
ATENCIÓN: Si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-877-739-1370 (TTY:
711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-877-739-1370 (TTY: 711) 번으로 전화해주십시오.
CHÚ Ý: Nếu bạn nói Tiếng Việt, chúng tôi có các dịch vụ hỗ trợ
ngôn ngữ miễn phí dành cho bạn. Xin gọi số 1-877-739-1370 (TTY:
711).
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-877-739-1370
(TTY: 711)。
1370-739-877-1، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.
اتصل برقم العربيةملحوظة: إذا كنت تتحدث
.(TTY :711) الهاتف النصي)
PAUNAWA: Kung nagsasalita ka ng Tagalog, may mga magagamit kang
libreng serbisyo ng tulong sa wika. Tumawag sa 1-877-739-1370 (TTY:
711).
فراهم می باشد. با شماره شما برای رایگان بصورت زبانی تسھیالت
کنید، می صحبت فارسی زبان هب اگر :هتوج 1-877-739-1370 (TTY: 711)
بگیرید تماس.
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት
ተዘጋጀተዋል፡፡ ወደ ሚከተለው
ቁጥር ይደውሉ 1-877-739-1370 (መስማት ለተሳናቸው: 711).
توجہ ديں: اگر آپ اردو بولتے ہيں تو، زبان سے متعلق اعانت کی
خدمات، آپ کے ليے مفت دستياب ہے۔
1-877-739-1370 (TTY: 711) پر کال کريں۔
ATTENTION: Si vous parlez français, des services d'aide
linguistique vous sont proposés gratuitement. Appelez le
1-877-739-1370 (ATS: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
бесплатные услуги
перевода. Звоните 1-877-739-1370 (линия TTY: 711).
ध्यान दें: यदद आप ह िंदी बोलते ैं तो आपके ललए मुफ्त में भाषा स
ायता सेवाएिं उपलब्ध ैं।
1-877-739-1370 (TTY: 711) पर कॉल करें।
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos
sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:
1-877-739-1370 (TTY: 711).
10
-
মননোনযোগ দিনঃ আপদন যদি বোাংলোনে কথো বলনে পোনেন, েোহনল দনঃখেচোয়
ভোষো সহোয়েো পদেনষবো উপলব্ধ আনে। ফ োন করুন 1-877-739-1370 (TTY:
711)
YI LE: I balè u pot tila hop won ngim bod i kobol mahop i la
hola wè ni hop won, u saa béé to yom. Sébél 1-877-739-1370 (TTY:
711).
GENU NTI: Ọ buru na ina asu asusu Igbo, enyemaka na-ahazi asusu,
bu n’efu, diri gi mgbe niile. Kpoo nomba ndi a 1-877-739-1370 (TTY:
711).
AKIYESI: Bi o ba nsọ èdè Yorùbá, ọfé ni iranlọwọ lori èdè wa fun
yin. Ẹ pe ẹrọ-ibanisọrọ yi 1-877-739-1370 (TTY: 711).
11
SummaryofBenefitsGoldPlat2020.pdfNotice of Non-Discrimination No
name - wo carats.pdfMLI.pdf