Getting more out of your health care dollar.
Why pay separate monthly premiums for a Medicare
supplement plan and a Prescription Drug Plan (PDP) when you can get
great benefits in one easy, no-hassle plan - for a price that can
be less than the combined cost of a supplement and PDP?
Need help choosing a plan? Call us today at 1-888-830-VIVA
(8482) or click here to contact us.
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|
Amount You Pay |
| Premium |
$99 in addition to part B monthly
premium1 |
| Annual Out of Pocket Limit |
$6,700 |
| Inpatient Copay (includes includes IP Psych) |
$175/day for days 1-6;
$0/day for days 7-90 |
| SNF Copay |
$50/day for days 1-30;
$0/day for days 31-100. |
| PCP Copay |
$10 |
| Specialist Copay |
$30 |
| Outpatient mental health/sub abuse |
$30 |
| Outpatient Surgery Copay |
$225 per procedure
|
| Ambulance Services |
$150 |
| ER Visit |
$65 (Waived if admitted to hospital within 24
hours) |
| Urgent Care |
$10-$30 |
| Outpatient Rehab |
$30 |
| DME/prosthetics |
20% |
| Lab Copay |
$0 |
| Diagnostic procedures/tests |
$0 |
| X-Ray Copay |
$0 |
| Diagnostic Radiology |
$0 |
| Radiation Therapy |
$0 |
| Prescription Coverage4,5 |
Yes |
| 1-Preferred Generics |
$5 |
| 2-Generics |
$10 |
| 3-Preferred Brand |
$45 |
| 4-Non-Preferred Brand |
$75 |
| 5-Specialty |
33% |
| Prescription Gap Coverage |
Member pays 86% for generics on Tiers 1,
2, & 5. There is also a 50% discount on the
negotiated price (excluding the dispensing
fee) for those brand name drugs from
manufacturers that have agreed to pay the
discount. Tier 5 will only be covered up to a
31 day supply. |
| Health/Wellness Education |
$20 per month at a participating health club |
This table is a brief listing of copays for frequently used
benefits for VIVA MEDICARE Plus Rx Premier. Other plans
not shown here are available. This is a summary only.
For complete details on plan benefits and limitations, please see
the Evidence of Coverage.
1 You must continue to pay your Part B premium.
Individuals must have both Part A and Part B to enroll
2 You must use plan providers except in an emergency,
urgent care situations, or for out-of-area renal dialysis or other
services. If you obtain routine care from out-of-network providers
neither Medicare nor VIVA Medicare Plus will be responsible for the
costs
3 Limitations, copayments, and restrictions may apply.
View the Evidence of Coverage for more information
4 You may be able to get Extra Help to pay for your
prescription drug premiums and costs. To see if you qualify for
Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should
call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social
Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday
through Friday. TTY users should call, 1-800-325-0778; or Your
Medicaid Office
5 VIVA Medicare Plus Rx Extra Value is a
Coordinated Care plan
with a Medicare Advantage contract and a
contract with the Alabama Medicaid program.