Inter Valley Health Plan Service To Seniors (HMO)
H0545 - 001 - 0
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Inter Valley Health Plan Service To Seniors (HMO) is a Medicare Advantage (Part C) Plan by Inter Valley Health Plan.
This page features plan details for 2022 Inter Valley Health Plan Service To Seniors (HMO) H0545 – 001 – 0 available in Counties: LA, RV, OC and SB.
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
Inter Valley Health Plan Service To Seniors (HMO) is offered in the following locations.
Plan Overview
Inter Valley Health Plan Service To Seniors (HMO) offers the following coverage and cost-sharing.
| Insurer: | Inter Valley Health Plan |
| Health Plan Deductible: | $0 |
| MOOP: | $1,000.00 |
| Drugs Covered: | Yes |
Ready to sign up for Inter Valley Health Plan Service To Seniors (HMO) ?
Premium Breakdown
Inter Valley Health Plan Service To Seniors (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 | $0.00 | $170.10 |
- 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
Inter Valley Health Plan Service To Seniors (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 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 $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.
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
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | |||
| 2 (Generic) | $5.00 copay | |||
| 6 (Select Diabetic Drugs) | $11.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $15.00 copay | $10.00 copay | ||
| 6 (Select Diabetic Drugs) | $33.00 copay | $22.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 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.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Inter Valley Health Plan Service To Seniors (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | $0-87 copay |
| Endodontics: | $43-584 copay |
| Extractions: | $62-283 copay |
| Non-routine services: | $50-68 copay |
| Periodontics: | $35-1,178 copay |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $29-2,300 copay |
| Restorative services: | $47-700 copay |
Dental (preventive)
| 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 procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $60 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) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $195 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (authorization required) (referral required) |
| Hearing aids: | $599-899 copay (limits may apply) |
| Hearing exam: | $0 copay (authorization required) (referral required) |
Hospital coverage (inpatient)
| $0 copay (authorization required) |
Hospital coverage (outpatient)
| $0 copay (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $1,000 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 10% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 10% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 15% coinsurance (authorization required) |
| Other Part B drugs: | 15% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $75 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization 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) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization required) (referral required) |
Rehabilitation services
| Occupational therapy visit: | $0 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $0 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $50 per day for days 21 through 100 (authorization required) |
Transportation
| $0 copay (limits may apply) |
Vision
| Contact lenses: | Not covered |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization required) (referral required) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) (authorization required) (referral required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| 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 Service To Seniors (HMO) ?