Advantage Care by Ultimate (HMO C-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Ultimate Health Plans.
This page features plan details for 2024 Advantage Care by Ultimate (HMO C-SNP) H2962 – 051 – 0 available in Polk county.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Advantage Care by Ultimate (HMO C-SNP) is offered in the following locations.
Advantage Care by Ultimate (HMO C-SNP) offers the following coverage and cost-sharing.
Special Needs Plan Type: | Chronic or Disabling Condition |
Conditions Covered: | Cardiovascular Disorders, Chronic Heart Failure and Diabetes |
Insurer: | Ultimate Health Plans |
Health Plan Deductible: | $0.00 |
MOOP: | $3,200 In-network |
Drugs Covered: | Yes |
Ready to sign up for Advantage Care by Ultimate (HMO C-SNP) ?
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Advantage Care by Ultimate (HMO C-SNP) qualifies for a monthly Medicare Give Back Benefit of $164.90.
Premium Reduction: | $164.90 |
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$174.70 | $0.00 | $0.00 | $164.90 | $9.80 |
Advantage Care by Ultimate (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $5,030.00 |
Catastrophic Coverage Limit: | $8,000.00 |
Drug Benefit Type: | Enhanced |
Additional Gap Coverage: | Yes |
Formulary Link: | Formulary Link |
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
Part D | LIS Full |
---|---|
$0.00 | $0.00 |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Generic) | $0.00 copay | |||
2 (Preferred Brand) | $25.00 copay | |||
3 (Non-Preferred Drug) | $65.00 copay | |||
4 (Specialty Tier) | 33% | |||
5 (Select Care Drugs) | $10.00 copay |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Generic) | ||||
2 (Preferred Brand) | ||||
3 (Non-Preferred Drug) | ||||
4 (Specialty Tier) | ||||
5 (Select Care Drugs) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Generic) | $0.00 copay | $0.00 copay | ||
2 (Preferred Brand) | $75.00 copay | $50.00 copay | ||
3 (Non-Preferred Drug) | $195.00 copay | $130.00 copay | ||
4 (Specialty Tier) | ||||
5 (Select Care Drugs) | $30.00 copay | $20.00 copay |
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Generic) | $0.00 copay | |||
5 (Select Care Drugs) | $10.00 copay | |||
Generic drugs | ||||
Brand-name drugs |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Generic) | $0.00 copay | $0.00 copay | ||
5 (Select Care Drugs) | $30.00 copay | $20.00 copay | ||
Generic drugs | ||||
Brand-name drugs |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced benefit type.
Advantage Care by Ultimate (HMO C-SNP) also provides the following benefits.
$0 |
In-network | No |
$3,200 In-network |
No |
In-network | No |
$195 copay per visit (Authorization is required.) (Referral is required.) |
Primary | $0 copay (Not applicable.) (Not applicable.) |
Specialist | $15 copay per visit (Authorization is required.) (Referral is required.) |
$0 copay (Authorization is required.) (Referral is required.) |
Emergency | $75 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Urgent care | $10 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Diagnostic tests and procedures | $0-195 copay or 0-20% coinsurance (Authorization is required.) (Referral is required.) |
Lab services | $0-195 copay or 0-20% coinsurance (Authorization is required.) (Referral is required.) |
Diagnostic radiology services (e.g., MRI) | $25-195 copay (Authorization is required.) (Referral is required.) |
Outpatient x-rays | $0-195 copay (Authorization is required.) (Referral is required.) |
Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Upgrades | $30-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Occupational therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
$150 copay (Not applicable.) (Not applicable.) |
$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Foot exams and treatment | $15 copay (Authorization is not required.) (Referral is required.) |
Routine foot care | Not covered (Not applicable.) (Not applicable.) |
Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is required.) |
Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
$160 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
Inpatient hospital – psychiatric | $160 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
Outpatient group therapy visit with a psychiatrist | $10 copay (Authorization is not required.) (Referral is not required.) |
Outpatient individual therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
Outpatient group therapy visit | $10 copay (Authorization is not required.) (Referral is not required.) |
Outpatient individual therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
$0 per day for days 1 through 20 $150 per day for days 21 through 38 $0 per day for days 39 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Advantage Care by Ultimate (HMO C-SNP) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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