Inter Valley Health Plan Vitality Plus (HMO) is a Medicare Advantage (Part C) Plan by Inter Valley Health Plan.
This page features plan details for 2022 Inter Valley Health Plan Vitality Plus (HMO) H0545 – 015 – 0 available in LA, San Bernardino, Riverside and Orange Counties.
Inter Valley Health Plan Vitality Plus (HMO) is offered in the following locations.
Inter Valley Health Plan Vitality Plus (HMO) offers the following coverage and cost-sharing.
Insurer: | Inter Valley Health Plan |
Health Plan Deductible: | $0 |
MOOP: | $5,900.00 |
Drugs Covered: | Yes |
Ready to sign up for Inter Valley Health Plan Vitality Plus (HMO) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $0.00 | $33.20 | $0.00 | $203.30 |
Inter Valley Health Plan Vitality Plus (HMO) 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 |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$33.20 | $24.90 | $16.60 | $8.30 | $0.00 |
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.
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 Vitality Plus (HMO) 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: | Not covered |
Dental x-ray(s): | Not covered |
Fluoride treatment: | Not covered |
Oral exam: | Not covered |
Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) (referral required) |
Diagnostic tests and procedures: | 20% coinsurance (authorization required) (referral required) |
Lab services: | 20% coinsurance (authorization required) (referral required) |
Outpatient x-rays: | 20% coinsurance (authorization required) (referral required) |
Primary: | $0 copay |
Specialist: | $0 copay (authorization required) (referral required) |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $0 copay |
Foot exams and treatment: | 20% coinsurance (authorization required) (referral required) |
Routine foot care: | $0 copay (limits may apply) (authorization required) (referral required) |
20% coinsurance |
$0.00 |
In-Network: No |
Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral required) |
Hearing aids: | $599-899 copay (authorization required) (referral required) |
Hearing exam: | 20% coinsurance (authorization required) (referral required) |
Contact plan for details (authorization required) |
20% coinsurance per visit (authorization required) (referral required) |
$5,900 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: | Contact plan for details (authorization required) |
Outpatient group therapy visit with a psychiatrist: | 20% coinsurance (authorization required) (referral required) |
Outpatient group therapy visit: | 20% coinsurance (authorization required) (referral required) |
Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance (authorization required) (referral required) |
Outpatient individual therapy visit: | 20% coinsurance (authorization required) (referral required) |
Yes |
$0 copay (authorization required) (referral required) |
Occupational therapy visit: | 20% coinsurance (authorization required) (referral required) |
Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) (referral required) |
Contact plan for details (authorization required) (referral required) |
$0 copay (limits may apply) (authorization required) (referral required) |
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 |
Covered |
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 Vitality Plus (HMO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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