Perennial Advantage Premier (HMO I-SNP) is a Medicare Advantage Special Needs Plan by Perennial Advantage.
This page features plan details for 2024 Perennial Advantage Premier (HMO I-SNP) H3419 – 004 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Perennial Advantage Premier (HMO I-SNP) is offered in the following locations.
Perennial Advantage Premier (HMO I-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Institutional |
| Conditions Covered: |
| Insurer: | Perennial Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Perennial Advantage Premier (HMO I-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
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $0.00 | $ |
Perennial Advantage Premier (HMO I-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: | Enhanced |
| Additional Gap Coverage: | No |
| Formulary Link: | Formulary Link |
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 |
|---|---|
| $0.00 | $0.00 |
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.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $15.00 copay | $15.00 copay | ||
| 3 (Preferred Brand) | $45.00 copay | $45.00 copay | ||
| 4 (Non-Preferred Brand) | $95.00 copay | $95.00 copay | ||
| 5 (Specialty Tier) | 25% | 25% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Brand) | ||||
| 5 (Specialty Tier) |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $45.00 copay | $45.00 copay | ||
| 3 (Preferred Brand) | $135.00 copay | $135.00 copay | ||
| 4 (Non-Preferred Brand) | $285.00 copay | $285.00 copay | ||
| 5 (Specialty Tier) |
| 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 $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced benefit type.
Perennial Advantage Premier (HMO I-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $3,900 In-network |
| No |
| In-network | No |
| 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not 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 not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $225 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $225 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Coming soon (Authorization is required.) (Referral is not required.) |
Ready to sign up for Perennial Advantage Premier (HMO I-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