iCare Medicare Plan (HMO D-SNP)
H2237 - 001 - 0
(4.5 / 5)
iCare Medicare Plan (HMO D-SNP) is a Medicare Advantage Special Needs Plan by iCare.
This page features plan details for 2024 iCare Medicare Plan (HMO D-SNP) H2237 – 001 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
iCare Medicare Plan (HMO D-SNP) is offered in the following locations.
Plan Overview
iCare Medicare Plan (HMO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | iCare |
| Health Plan Deductible: | Coming soon |
| MOOP: | $8,850 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 iCare Medicare Plan (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
iCare Medicare Plan (HMO D-SNP) has a monthly premium of $48.10. 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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $48.10 | $0.00 | $ |
- 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
iCare Medicare Plan (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Basic |
| Additional 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 Full |
|---|---|
| $48.10 | $0.00 |
Initial Coverage Phase
After you pay your $545.00 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 $5,030.00. 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 |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
| 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 $8,000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
iCare Medicare Plan (HMO D-SNP) also provides the following benefits.
| Coming soon |
| In-network | No |
| $8,850 In-network |
| No |
| In-network | Yes, contact plan for further details |
| 0% or 20% coinsurance per visit (Authorization is required.) (Referral is required.) |
| Primary | 0% or 20% coinsurance per visit (Not applicable.) (Not applicable.) |
| Specialist | 0% or 20% coinsurance per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 or $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | 0% or 20% coinsurance per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 0% or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Lab services | $0 or $30 copay or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $0 or $200-300 copay or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 or $50 copay or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Hearing exam | 0% or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | 0% or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | 0% or 20% coinsurance (Authorization is required.) (Referral is required.) |
| $0 or $300 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Foot exams and treatment | 0% or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0% or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | $0 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $0 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| $0 or $2,080 per stay (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $0 or $1,937 per stay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | 0% or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | 0% or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | 0% or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | 0% or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $0 or $203 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for iCare Medicare Plan (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST