Amerivantage Dual Coordination (HMO D-SNP)
H2593 - 032 - 0
(3.5 / 5)
Amerivantage Dual Coordination (HMO D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Amerigroup.
This page features plan details for 2023 Amerivantage Dual Coordination (HMO D-SNP) H2593 – 032 – 0 available in Select Counties in Texas.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
Locations
Amerivantage Dual Coordination (HMO D-SNP) is offered in the following locations.
Plan Overview
Amerivantage Dual Coordination (HMO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | Amerigroup |
| Health Plan Deductible: | $0.00 |
| MOOP: | $7,550 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 Amerivantage Dual Coordination (HMO D-SNP) ?
Premium Breakdown
Amerivantage Dual Coordination (HMO D-SNP) has a monthly premium of $18.70. 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 |
|---|---|---|---|---|
| $164.90 | $0.00 | $18.70 | $0.00 | $183.60 |
- 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
Amerivantage Dual Coordination (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $505.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| 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 |
|---|---|---|---|---|
| $18.70 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $505.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $15.00 copay | $15.00 copay | $15.00 copay | |
| 2 (Generic) | $20.00 copay | $20.00 copay | $20.00 copay | |
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | $47.00 copay | |
| 4 (Non-Preferred Drug) | $95.00 copay | $100.00 copay | $95.00 copay | |
| 5 (Specialty Tier) | 25% | 25% | 25% | |
| 6 (Select Care Drugs) | $10.00 copay | $10.00 copay | $10.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $45.00 copay | $45.00 copay | $45.00 copay | |
| 2 (Generic) | $60.00 copay | $60.00 copay | $60.00 copay | |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $141.00 copay | |
| 4 (Non-Preferred Drug) | $285.00 copay | $300.00 copay | $285.00 copay | |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $30.00 copay | $30.00 copay | $30.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Amerivantage Dual Coordination (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) (referral not required) |
| Endodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | 0% or 20% coinsurance (authorization required) (referral required) |
| Diagnostic tests and procedures: | 0% or 20% coinsurance (authorization required) (referral required) |
| Lab services: | 0% or 20% coinsurance (authorization required) (referral required) |
| Outpatient x-rays: | 0% or 20% coinsurance (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $0 or $90 copay per visit (always covered) |
| Urgent care: | $0 or $60 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | 0% or 20% coinsurance (authorization required) (referral required) |
| Routine foot care: | $0 copay (no limits) (authorization required) (referral required) |
Ground ambulance
| 0% or 20% coinsurance |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral required) |
| Hearing aids: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Hearing exam: | 0% or 20% coinsurance (authorization required) (referral required) |
Hospital coverage (inpatient)
| In 2023 the amounts for each benefit period are $0 or: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| 0% or 20% coinsurance per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0% or 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 0% or 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 0% or 20% coinsurance (authorization required) |
| Other Part B drugs: | 0% or 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In 2023 the amounts for each benefit period are $0 or: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | 0% or 20% coinsurance (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | 0% or 20% coinsurance (authorization required) (referral required) |
| Outpatient individual therapy visit: | 0% or 20% coinsurance (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | 0% or 20% coinsurance (authorization required) (referral required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | 0% or 20% coinsurance (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | 0% or 20% coinsurance (authorization required) (referral required) |
Skilled Nursing Facility
| In 2023 the amounts for each benefit period are $0 or: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| $0 copay (limits may apply) (authorization not required) (referral not required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Amerivantage Dual Coordination (HMO D-SNP) ?