Inter Valley Health Plan Desert Preferred Choice (HMO) is a Medicare Advantage (Part C) Plan by Inter Valley Health Plan.
This page features plan details for 2022 Inter Valley Health Plan Desert Preferred Choice (HMO) H0545 – 012 – 0 available in Riverside County.
Inter Valley Health Plan Desert Preferred Choice (HMO) is offered in the following locations.
Inter Valley Health Plan Desert Preferred Choice (HMO) offers the following coverage and cost-sharing.
Insurer: | Inter Valley Health Plan |
Health Plan Deductible: | $0 |
MOOP: | $1,500.00 |
Drugs Covered: | Yes |
Ready to sign up for Inter Valley Health Plan Desert Preferred Choice (HMO) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
Inter Valley Health Plan Desert Preferred Choice (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $4,430.00 |
Catastrophic Coverage Limit: | $7,050.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | Yes |
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 $0.00 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.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | |||
2 (Generic) | $12.00 copay | |||
6 (Select Diabetic Drugs) | $11.00 copay | $11.00 copay |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $36.00 copay | $36.00 copay | ||
6 (Select Diabetic Drugs) | $33.00 copay | $33.00 copay |
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 $7,050.00, 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) |
Inter Valley Health Plan Desert Preferred Choice (HMO) also provides the following benefits.
In-Network: No |
Diagnostic services: | $0-87 copay (authorization required) (referral required) |
Endodontics: | $43-584 copay (authorization required) (referral required) |
Extractions: | $62-283 copay (authorization required) (referral required) |
Non-routine services: | $50-68 copay (authorization required) (referral required) |
Periodontics: | $35-1,178 copay (authorization required) (referral required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | $29-2,300 copay (authorization required) (referral required) |
Restorative services: | $47-700 copay (authorization required) (referral required) |
Cleaning: | $5 copay (limits may apply) |
Dental x-ray(s): | $0 copay (limits may apply) |
Fluoride treatment: | $5-12 copay (limits may apply) |
Oral exam: | $0 copay (limits may apply) |
Diagnostic radiology services (e.g., MRI): | $40 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: | $120 copay per visit (always covered) |
Urgent care: | $0 copay |
Foot exams and treatment: | $0 copay (authorization required) (referral required) |
Routine foot care: | Not covered |
$200 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral required) |
Hearing aids: | $0 copay (limits may apply) (authorization required) (referral required) |
Hearing exam: | $0 copay (authorization required) (referral required) |
$0 copay (authorization required) (referral required) |
$0 copay (authorization required) (referral required) |
$1,500 In-network |
Diabetes supplies: | $0 copay (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | 0-10% coinsurance per item (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: | $912 per stay (authorization required) (referral required) |
Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization required) (referral required) |
Outpatient group therapy visit: | $0 copay (authorization required) (referral required) |
Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization required) (referral required) |
Outpatient individual therapy visit: | $0 copay (authorization required) (referral required) |
Yes |
$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 per day for days 1 through 20 $100 per day for days 21 through 35 $0 per day for days 36 through 100 (authorization required) (referral required) |
$0 copay (limits may apply) (authorization required) (referral required) |
Contact lenses: | $0 copay (limits may apply) |
Eyeglass frames: | Not covered |
Eyeglass lenses: | Not covered |
Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
Other: | Not covered |
Routine eye exam: | $0 copay (limits may apply) |
Upgrades: | Not covered |
Covered (authorization required) (referral required) |
Preventive dental: | Monthly Premium: | $14.80 |
Preventive dental: | Deductible: | N/A |
Comprehensive dental: | Monthly Premium: | $14.80 |
Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Inter Valley Health Plan Desert Preferred Choice (HMO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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