Erickson Advantage Liberty with Drugs (HMO-POS)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by UnitedHealthcare
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
 4.5
out of 5 stars

State: Texas

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
$6,700 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $0-30 copay per visit
Out-of-network: 30% coinsurance per visit
In-network: $50 copay per visit
Out-of-network: 30% coinsurance per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0-100 copay
Out-of-network: 30% coinsurance
In-network: $15 copay
Out-of-network: $20 copay
$90 copay per visit (always covered)
$30 copay per visit (always covered)

Hospital Services

In-network: $300 per day for days 1 through 7
$0 per day for days 8 through 90
$0 per day for days 91 and beyond
Out-of-network: 30% per stay
In-network: $0-300 copay per visit
Out-of-network: 30% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 57
$0 per day for days 58 through 100
Out-of-network: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: 0-30% coinsurance

Ambulance

In-network: $250 copay
Out-of-network: $250 copay

Therapy services

In-network: $40 copay
Out-of-network: 30% coinsurance
In-network: $40 copay
Out-of-network: 30% coinsurance

Mental health services

In-network: $40 copay
Out-of-network: 30% coinsurance
In-network: $40 copay
Out-of-network: 30% coinsurance
In-network: $20 copay
Out-of-network: 30% coinsurance
In-network: $20-40 copay
Out-of-network: 30% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item

Prescription Drug Benefits

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

TiersInitial coverage phaseGap coverage phase1Catastrophic coverage phase
Preferred Generic$5.00 copay


Generic drugs :
$3.70 copay or 5% (whichever costs more)

Brand-name drugs :
$9.20 copay or 5% (whichever costs more)

Generic$20.00 copay$20.00 copay
Preferred Brand$45.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier25%
1 * The above cost-sharing only applies to some drugs on this tier. For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Extra Benefits

Hearing

In-network: $0 copay
Out-of-network: 30% coinsurance
Not covered
In-network: $375-2,075 copay
Out-of-network: $375 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Not covered
Not covered
Not covered
Not covered
Limited coverage
Limited coverage
 4.5
 5
 5
 4
 4
No Rating
 4.5
 5
 4
 5
 4

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