MVP Medicare Secure with Part D (HMO-POS)

MVP Medicare Secure with Part D (HMO-POS) H3305-030 Plan Details
4.5 out of 5 stars

MVP Medicare Secure with Part D (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by MVP Health Care, Inc..
Plan ID: H3305-030.

$15.00
Monthly Premium

MVP Medicare Secure with Part D (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by MVP Health Care, Inc..
Plan ID: H3305-030.

MVP Medicare Secure with Part D (HMO-POS) H3305-030 Plan Details
4.5 out of 5 stars

MVP Medicare Secure with Part D (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by MVP Health Care, Inc..
Plan ID: H3305-030.

$15.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $300
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
POS (Out-of-Network):

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$385.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Maximum out of Pocket $1925.00
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $65.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $500.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $200.00 to $500.00
Copayment for Medicare Covered Ambulance Services - Air $200.00 to $500.00

Health Care Services and Medical Supplies

MVP Medicare Secure with Part D (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 5%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $20.00
Copayment for Medicare-covered Lab Services $0.00 to $10.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $50.00 to $200.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $50.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$370.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Maximum out of Pocket $1850.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $400.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $400.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $325.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Prior Authorization Required for Podiatry Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 1 visit every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year
Maximum Plan Benefit of $120.00 every year
Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Prior Authorization Required for Comprehensive Dental
Prior authorization required
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $300.00 every year

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 20%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Maximum Plan Benefit of $300.00 every year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 3 visits every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Up to two TruHearing branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. You must see a TruHearing provider to use this benefit. Copayment Structure TruHearing Advanced - $699 copayment per hearing aid TruHearing Premium - $999 copayment per hearing aid Hearing aid purchases includes: • 3 provider visits within first year of hearing aid purchase • 45 day trial period • 3 year extended warranty • 48 batteries per aid Benefit does not include or cover any of the following: • Ear molds • Hearing aid accessories • Additional provider visits • Extra batteries • Hearing aids that are not the TruHearing branded hearing aids • Hearing aid return fees • Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan. Hearing aid copayments are not subject to
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%

    Prescription Drug Costs and Coverage

    The MVP Medicare Secure with Part D (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $10.00
    • Standard mail order $10.00
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Standard mail order N/A
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $30.00
    • Standard mail order $20.00