Great Plains Medicare Advantage (HMO I-SNP)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by Great Plains Medicare Advantage
Additional Coverage
HearingVisionDental
Overall Government Star Rating
No Rating (new plans)
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$40
$0
$40
$226 per year for in-network services.
$8,300 In-network
No
Yes
Yes
Yes

Doctor Services

$0 copay
20% coinsurance per visit

Tests, labs, & imaging

20% coinsurance
$0 copay
20% coinsurance
20% coinsurance
$90 copay per visit (always covered)
20% coinsurance per visit (always covered)

Hospital Services

In 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90
20% coinsurance per visit

Skilled nursing facility

In 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100

Preventive services

$0 copay

Ambulance

20% coinsurance

Therapy services

20% coinsurance
20% coinsurance

Mental health services

20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

Opioid treatment services

Covered

Other services

20% coinsurance per item
20% coinsurance per item
20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic
Preferred Brand
Non-Preferred Drug
Specialty Tier

Part B Drugs

20% coinsurance
20% coinsurance

Hearing

20% coinsurance
$0 copay
$0 copay

Preventive Dental

$0 copay
$0 copay
Not covered
$0 copay

Comprehensive dental

$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay

Vision

$0 copay
$0 copay
$0 copay
Not covered
Not covered
$0 copay

Other benefits

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Limited coverage
No Rating (new plans)
No Rating (new plans)
No Rating (new plans)
No Rating (new plans)
No Rating (new plans)
No Rating (new plans)
 4
 2
No Rating (new plans)
No Rating (new plans)
 4

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