Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 is a Medicare Advantage (Part C) Special Needs Plan by Brandman Health Plan.
This page features plan details for 2022 Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 available in .
Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 is offered in the following locations.
Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 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: | Brandman Health Plan |
| Health Plan Deductible: | 0.00 |
| MOOP: | $999 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $ | $ | $0.00 | $ | $ |
Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $ |
| Initial Coverage Limit: | $ |
| Catastrophic Coverage Limit: | $ |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Some Generics and Few Brands |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
After you pay your $ 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 $. Once you reach that amount, you will enter the next coverage phase.
After your total drug costs (including what this plan has paid and what you have paid) reach $, you will pay no more than the amounts below for any drug tier until you reach $.
| 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 $, 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) |
Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 also provides the following benefits.
| In-Network: No |
| Diagnostic services: | $0 copay (limits may apply) |
| Endodontics: | $0 copay (limits may apply) |
| Extractions: | $0 copay (limits may apply) |
| Non-routine services: | $0 copay (limits may apply) |
| Periodontics: | $0 copay (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) |
| Restorative services: | $0 copay (limits may apply) |
| 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 radiology services (e.g., MRI): | $0 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0 copay (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral required) |
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
| Emergency: | $75 copay per visit (always covered) |
| Urgent care: | $0 copay |
| Foot exams and treatment: | $0 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
| $125 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | $0 copay (limits may apply) |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | $0 copay |
| $0 copay (authorization required) (referral required) |
| $0 copay (authorization required) (referral required) |
| $999 In-network |
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | $0 copay (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 0-20% coinsurance per item (authorization required) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | $0 per day for days 1 through 60 $329 per day for days 61 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
| Outpatient group therapy visit: | 20% coinsurance (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
| Outpatient individual therapy visit: | 20% coinsurance (authorization required) (referral required) |
| No |
| $0 copay |
| Occupational therapy visit: | $10 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $10 copay (authorization required) (referral required) |
| $0 copay (authorization required) (referral required) |
| $0 copay (limits may apply) (authorization required) (referral required) |
| 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) |
| Covered (authorization required) (referral required) |
Ready to sign up for Brandman Health Plan (Arise) (HMO C-SNP) – H7594 – 1 – 0 ?
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