Ascension Complete Sacred Heart Reward (HMO)
H8225 - 002 - 0
(3.5 / 5)
Ascension Complete Sacred Heart Reward (HMO) is a Medicare Advantage (Part C) Plan by Ascension Complete.
This page features plan details for 2022 Ascension Complete Sacred Heart Reward (HMO) H8225 – 002 – 0 available in Pensacola Metro Area.
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
Ascension Complete Sacred Heart Reward (HMO) is offered in the following locations.
Plan Overview
Ascension Complete Sacred Heart Reward (HMO) offers the following coverage and cost-sharing.
| Insurer: | Ascension Complete |
| Health Plan Deductible: | $0 |
| MOOP: | $2,900.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $480 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Ascension Complete Sacred Heart Reward (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Ascension Complete Sacred Heart Reward (HMO) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Ascension Complete Sacred Heart Reward (HMO) has a monthly premium of $0. 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 | $0.00 | $100.00 | $70.10 |
- 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
Ascension Complete Sacred Heart Reward (HMO) 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: | 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 |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $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.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $3.95 copay or 5% (whichever costs more) |
| Brand-name drugs | $9.85 copay or 5% (whichever costs more) |
Additional Benefits
Ascension Complete Sacred Heart Reward (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization required) |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | $0 copay (limits may apply) (authorization required) |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization required) |
| Oral exam: | $0 copay (limits may apply) (authorization required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0-350 copay (authorization required) |
| Diagnostic tests and procedures: | $0-100 copay (authorization required) |
| Lab services: | $0-35 copay (authorization required) |
| Outpatient x-rays: | $40 copay (authorization required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $50 copay per visit |
Emergency care/Urgent care
| Emergency: | $120 copay per visit (always covered) |
| Urgent care: | $45 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $50 copay |
| Routine foot care: | $50 copay |
Ground ambulance
| $350 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered |
| Hearing aids – inner ear: | Not covered |
| Hearing aids – outer ear: | Not covered |
| Hearing aids – over the ear: | Not covered |
| Hearing exam: | $50 copay (authorization required) |
Hospital coverage (inpatient)
| $500 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) |
Hospital coverage (outpatient)
| $350 copay per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $2,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $465 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay |
| Outpatient group therapy visit: | $40 copay |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay |
| Outpatient individual therapy visit: | $40 copay |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay |
Rehabilitation services
| Occupational therapy visit: | $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | $40 copay (authorization required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) |
Transportation
| $0 copay (limits may apply) (authorization required) |
Vision
| Contact lenses: | Not covered |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | Not covered |
| Routine eye exam: | Not covered |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $23.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $23.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eye exams: | Monthly Premium: | $23.00 |
| Eye exams: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $23.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Ascension Complete Sacred Heart Reward (HMO) ?