Cooperative Advantage Premium (HMO I-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Group Health Cooperative of Eau Claire.
This page features plan details for 2022 Cooperative Advantage Premium (HMO I-SNP) H7598 – 001 – 0 available in Wisconsin.
Cooperative Advantage Premium (HMO I-SNP) is offered in the following locations.
Cooperative Advantage Premium (HMO I-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Institutional |
| Conditions Covered: |
| Insurer: | Group Health Cooperative of Eau Claire |
| Health Plan Deductible: | $0 |
| MOOP: | $7,550 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Cooperative Advantage Premium (HMO I-SNP) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $23.40 | $51.60 | $0.00 | $245.10 |
Cooperative Advantage Premium (HMO I-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 | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $51.60 | $41.00 | $30.50 | $19.90 | $9.30 |
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.
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.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
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) |
Cooperative Advantage Premium (HMO I-SNP) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | Not covered |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
| Cleaning: | $0 copay (limits may apply) (referral required) |
| Dental x-ray(s): | $0 copay (limits may apply) (referral required) |
| Fluoride treatment: | Not covered |
| Oral exam: | $0 copay (limits may apply) (referral required) |
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | 20% coinsurance (authorization required) |
| Lab services: | 20% coinsurance (authorization required) |
| Outpatient x-rays: | 20% coinsurance (authorization required) |
| Primary: | $0 copay |
| Specialist: | 20% coinsurance per visit |
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $65 copay per visit (always covered) |
| Foot exams and treatment: | 20% coinsurance (authorization required) |
| Routine foot care: | Not covered |
| $225 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | Not covered |
| Hearing aids: | $250 copay (limits may apply) |
| Hearing exam: | $0 copay |
| $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) |
| 20% coinsurance per visit (authorization required) |
| $7,550 In-network |
| Diabetes supplies: | 20% coinsurance 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) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient group therapy visit: | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient individual therapy visit: | 20% coinsurance (authorization required) |
| No |
| $0 copay |
| Occupational therapy visit: | 20% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) |
| $0 copay (authorization required) |
| $0 copay (limits may apply) (authorization required) |
| Contact lenses: | Not covered |
| 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: | Not covered |
| Not covered |
Ready to sign up for Cooperative Advantage Premium (HMO I-SNP) ?
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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SMID: MULTIPLAN_HCIHNDOGMED01_M
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