Plan ID: H5828-005

What You Need to Know:

  • Amerivantage Classic Plus (HMO-POS) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $0, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $4,900 per year (in-network).
  • Amerivantage Classic Plus (HMO-POS) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $0.

$0

Monthly Premium

Medicare Plan Features
Monthly Premium: $0
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$0 $0 $0 $0 $0 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H5828-006
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,900
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Hardeman, Tennessee: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
67 members New plan - No summary rating as of yet. New plan - not yet rated. New plan - not yet rated.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,708 drugs
Number of Members Enrolled in this Plan in Hardeman, Tennessee: 8,184 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $0.00 $0.00 $0.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
306 $2.00 609 $8.00 942 $42.00 1061 $95.00 700 33%

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4
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BlueAdvantage Emerald (PPO) (2023)Local PPO$5,900$0
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BlueAdvantage Diamond (PPO) (2023)Local PPO$3,700$0
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Cigna Premier Medicare (HMO-POS) (2023)Local HMO$6,700$200
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HumanaChoice R7315-002 (Regional PPO) (2023)Regional PPO$6,700$400
4
AARP Medicare Advantage Patriot (HMO) (2023)Local HMO *$3,200$-
5
HumanaChoice H5216-093 (PPO) (2023)Local PPO$6,700$150
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Aetna Medicare Premier Plan (PPO) (2023)Local PPO$7,500$0
5
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Aetna Medicare Value Plus Plan (HMO) (2023)Local HMO$7,500$250
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Cigna True Choice Medicare (PPO) (2023)Local PPO$6,300$0
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HumanaChoice H5216-180 (PPO) (2023)Local PPO$6,700$225
4
Humana Honor (HMO-POS) (2023)Local HMO *$5,900$-
4
AARP Medicare Advantage Plan 1 (HMO) (2023)Local HMO$5,900$0
5
WellCare Dividend (HMO) (2023)Local HMO$6,700$0
4
AARP Medicare Advantage Plan 2 (HMO) (2023)Local HMO$4,900$0
5
Amerivantage Classic (HMO) (2023)Local HMO$6,500$0
5
WellCare Patriot (HMO-POS) (2023)Local HMO *$4,500$-
4
Cigna Fundamental Medicare (HMO) (2023)Local HMO *$6,700$-
4
Cigna Preferred Medicare (HMO) (2023)Local HMO$6,700$0
4
Cigna Primary Medicare (HMO) (2023)Local HMO$6,700$445
4
Humana Gold Plus H4461-025 (HMO-POS) (2023)Local HMO$5,900$0
4
WellCare Compass (HMO) (2023)Local HMO$4,900$445
4
WellCare Value (HMO-POS) (2023)Local HMO$5,500$0
4
Medicare Advantage Plans by AMERIGROUP Community Care
Amerivantage Balance Plus (HMO) (2023)Local HMO$6,700$445
New plan - not yet rated.

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