Medica Advantage Solution with CHI Health (HMO)


Medicare Plan Details

2020 Plan
Monthly Premium
(select county for price)

 

by Medica
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
No Rating
out of 5 stars

State: Nebraska

Select your county to view the price for this plan

 


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

 

$0
$0
$0
$0
$3,500 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

$0 copay
$50 per visit

Tests, labs, & imaging

20%
$0 copay
20%
20%
$90 per visit (always covered)
$20-50 per visit (always covered)

Hospital Services

$350 per day for days 1 through 5
$0 per day for days 6 through 90
$295 per visit

Skilled nursing facility

$0 per day for days 1 through 20
$178 per day for days 21 through 100

Preventive services

$0 copay

Ambulance

$200

Therapy services

$40
$40

Mental health services

$40
$40
$40
$40

Opioid treatment services

Covered

Other services

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

Prescription Drug Benefits

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

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$10.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.60 copay or 5% (whichever costs more)

Brand-name drugs :
$8.95 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug50%
Specialty Tier26%

Part B Drugs

20%
20%

Extra Benefits

Hearing

$25
$0 copay
$599-899

Preventive Dental

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

Comprehensive dental

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

Vision

$35
$0 copay
$0 copay
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating

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