Provider Partners Texas Community Plan (HMO I-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Provider Partners Health Plans.
This page features plan details for 2023 Provider Partners Texas Community Plan (HMO I-SNP) H4054 – 002 – 0 available in Texas (Partial).
Provider Partners Texas Community Plan (HMO I-SNP) is offered in the following locations.
Provider Partners Texas Community Plan (HMO I-SNP) offers the following coverage and cost-sharing.
Special Needs Plan Type: | Institutional |
Conditions Covered: |
Insurer: | Provider Partners Health Plans |
Health Plan Deductible: | $226 per year for in-network services. |
MOOP: | $8,300 In-network |
Drugs Covered: | Yes |
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Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$164.90 | $0.00 | $25.00 | $0.00 | $189.90 |
Provider Partners Texas Community Plan (HMO I-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $505.00 |
Initial Coverage Limit: | $4,660.00 |
Catastrophic Coverage Limit: | $7,400.00 |
Drug Benefit Type: | Basic |
Gap Coverage: | No |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$25.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $505.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
25% | 25% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
25% | 25% |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Drug Type | Cost Share |
---|---|
Generic drugs | $4.15 copay or 5% (whichever costs more) |
Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Provider Partners Texas Community Plan (HMO I-SNP) also provides the following benefits.
In-Network: No |
Diagnostic services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Endodontics: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Extractions: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Non-routine services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Periodontics: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Restorative services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) (referral not required) |
Diagnostic tests and procedures: | 20% coinsurance (authorization not required) (referral not required) |
Lab services: | 20% coinsurance (authorization not required) (referral not required) |
Outpatient x-rays: | 20% coinsurance (authorization required) (referral not required) |
Primary: | $0 copay |
Specialist: | 20% coinsurance per visit (authorization not required) (referral not required) |
Emergency: | 20% coinsurance per visit (always covered) |
Urgent care: | 20% coinsurance per visit (always covered) |
Foot exams and treatment: | 20% coinsurance (authorization not required) (referral not required) |
Routine foot care: | $0 copay (limits may apply) (authorization not required) (referral not required) |
20% coinsurance |
$226 per year for in-network services. |
In-Network: No |
Fitting/evaluation: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids – inner ear: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids – outer ear: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids – over the ear: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing exam: | 20% coinsurance (authorization not required) (referral not required) |
In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
20% coinsurance per visit (authorization not required) (referral not required) |
$8,300 In-network |
Diabetes supplies: | 20% coinsurance per item (authorization not 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: | In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
Outpatient group therapy visit: | 20% coinsurance (authorization required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | 20% coinsurance (authorization required) (referral not required) |
Outpatient individual therapy visit: | 20% coinsurance (authorization required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance (authorization required) (referral not required) |
No |
$0 copay (authorization not required) (referral not required) |
Occupational therapy visit: | 20% coinsurance (authorization required) (referral not required) |
Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) (referral not required) |
In 2023 the amounts for each benefit period are: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100 (authorization required) (referral not required) |
$0 copay (limits may apply) (authorization not required) (referral not required) |
Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | Not covered (no limits) |
Other: | Not covered (no limits) |
Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Upgrades: | Not covered |
Covered (authorization not required) (referral not required) |
Ready to sign up for Provider Partners Texas Community Plan (HMO I-SNP) ?
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