Western Health Advantage MyCare Plus (HMO)
H2782 - 003 - 0
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Western Health Advantage MyCare Plus (HMO) is a Medicare Advantage (Part C) Plan by Western Health Advantage.
This page features plan details for 2023 Western Health Advantage MyCare Plus (HMO) H2782 – 003 – 0 available in Northern California.
IMPORTANT: This page features the 2023 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
Western Health Advantage MyCare Plus (HMO) is offered in the following locations.
Plan Overview
Western Health Advantage MyCare Plus (HMO) offers the following coverage and cost-sharing.
| Insurer: | Western Health Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,300 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Western Health Advantage MyCare Plus (HMO) ?
Premium Breakdown
Western Health Advantage MyCare Plus (HMO) has a monthly premium of $85.00. 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 |
|---|---|---|---|---|
| $164.90 | $54.20 | $30.80 | $0.00 | $249.90 |
- 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
Western Health Advantage MyCare Plus (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: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| 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 |
|---|---|---|---|---|
| $30.80 | $43.40 | $34.80 | $26.30 | $17.70 |
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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
| 2 (Generic) | $5.00 copay | $10.00 copay | $10.00 copay | |
| 3 (Preferred Brand) | $35.00 copay | $45.00 copay | $45.00 copay | |
| 4 (Non-Preferred Drug) | $90.00 copay | $100.00 copay | $100.00 copay | |
| 5 (Specialty Tier) | 33% | 33% | 33% | |
| 6 (Vaccines) | $0.00 copay | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
| 2 (Generic) | $15.00 copay | $30.00 copay | $25.00 copay | |
| 3 (Preferred Brand) | $105.00 copay | $135.00 copay | $112.50 copay | |
| 4 (Non-Preferred Drug) | $270.00 copay | $300.00 copay | $250.00 copay | |
| 5 (Specialty Tier) | ||||
| 6 (Vaccines) |
Gap Coverage Phase
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.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $5.00 copay | $0.00 copay | |
| 6 (Vaccines) | $0.00 copay | $0.00 copay | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | |
| 6 (Vaccines) |
| 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 $7,400.00, 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) |
Additional Benefits
Western Health Advantage MyCare Plus (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization not required) (referral required) |
| Endodontics: | $23-389 copay (no limits) (authorization not required) (referral required) |
| Extractions: | $0 copay (no limits) (authorization not required) (referral required) |
| Non-routine services: | $0-159 copay (no limits) (authorization not required) (referral required) |
| Periodontics: | $0 copay (limits may apply) (authorization not required) (referral required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $35-775 copay (limits may apply) (authorization not required) (referral required) |
| Restorative services: | $19-390 copay (limits may apply) (authorization not required) (referral required) |
Dental (preventive)
| 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 procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $50 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: | $20 copay per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $20 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $20 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $250 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (no limits) (authorization not required) (referral not required) |
| Hearing aids: | $699-999 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | $20 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $175 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $200 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,300 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (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) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $175 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $35 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $35 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | $35 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $35 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not 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 $150 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| 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): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | $20 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | $20 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Western Health Advantage MyCare Plus (HMO) ?