Advantage Plus by Ultimate (Partial) (HMO D-SNP)
H2962 - 038 - 0
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Advantage Plus by Ultimate (Partial) (HMO D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Ultimate Health Plans.
This page features plan details for 2022 Advantage Plus by Ultimate (Partial) (HMO D-SNP) H2962 – 038 – 0 available in Hernando and Pasco Counties.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Advantage Plus by Ultimate (Partial) (HMO D-SNP) is offered in the following locations.
Plan Overview
Advantage Plus by Ultimate (Partial) (HMO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | Ultimate Health Plans |
| Health Plan Deductible: | $0 |
| MOOP: | $500 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for Advantage Plus by Ultimate (Partial) (HMO D-SNP) ?
Premium Breakdown
Advantage Plus by Ultimate (Partial) (HMO D-SNP) has a monthly premium of $34.3. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $34.30 | $0.00 | $204.40 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Advantage Plus by Ultimate (Partial) (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $480.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No Gap Coverage |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $34.30 | $25.70 | $17.10 | $8.60 | $0.00 |
Initial Coverage Phase
After you pay your $480.00 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 $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Advantage Plus by Ultimate (Partial) (HMO D-SNP) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization required) |
| Endodontics: | Not covered |
| Extractions: | $0 copay (limits may apply) (authorization required) |
| Non-routine services: | Not covered |
| Periodontics: | $0 copay (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | 0% or 0-20% coinsurance (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $0 copay |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $0 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | $0 copay |
Hospital coverage (inpatient)
| $0 copay (authorization required) (referral required) |
Hospital coverage (outpatient)
| $0 copay (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $500 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | $0 copay (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | $0 copay (authorization required) |
Medicare Part B drugs
| Chemotherapy: | $0 copay (authorization required) |
| Other Part B drugs: | $0 copay (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $0 copay (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay |
| Outpatient group therapy visit: | $0 copay |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay |
| Outpatient individual therapy visit: | $0 copay |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization required) (referral required) |
Rehabilitation services
| Occupational therapy visit: | $0 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $0 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 copay (authorization required) (referral required) |
Transportation
| $0 copay |
Vision
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | $0 copay (limits may apply) |
| Eyeglass lenses: | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $0 copay (limits may apply) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization required) (referral required) |
Ready to sign up for Advantage Plus by Ultimate (Partial) (HMO D-SNP) ?