2022 Amerivantage Classic Plus (HMO-POS)

Amerivantage Classic Plus (HMO-POS) H5828-006 is a 2022 Medicare Advantage Plan or Part-C by AMERIGROUP Community Care available to residents in Tennessee. This plan includes additional prescription drug (Part-D) coverage. The Amerivantage Classic Plus (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,900 out-of-pocket. This can be a extremely nice safety net.

Amerivantage Classic Plus (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

AMERIGROUP Community Care works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Amerivantage Classic Plus (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from AMERIGROUP Community Care and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from AMERIGROUP Community Care except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 AMERIGROUP Community Care Medicare Advantage Plan Costs

Amerivantage Classic Plus (HMO-POS) Part-C Premium

AMERIGROUP Community Care charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5828-006 Part-D Deductible and Premium

Amerivantage Classic Plus (HMO-POS) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This AMERIGROUP Community Care plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by AMERIGROUP Community Care above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

AMERIGROUP Community Care Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This AMERIGROUP Community Care plan does offer additional coverage through the gap.

H5828-006 Formulary or Drug Coverage

Amerivantage Classic Plus (HMO-POS) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Amerivantage Classic Plus (HMO-POS) H5828-006 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$2	$7
Tier 2	$8	$13
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	33%	33%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Amerivantage Classic Plus (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	70% coinsurance
Extractions	50% coinsurance
Non-routine services	Not covered
Periodontics	70% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	70% coinsurance
Restorative services	50% coinsurance

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$130-220 copay
Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-150 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Lab services	$0-10 copay
Lab services	40% coinsurance (Out-of-Network)
Outpatient x-rays	$50-110 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$30 copay per visit (Out-of-Network)
Primary	$0 copay
Specialist	$50 copay per visit (Out-of-Network)
Specialist	$30 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$30 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay (Out-of-Network)
Foot exams and treatment	$0-30 copay
Routine foot care	$0 copay

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Ground Ambulance

$275 copay
$275 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Hearing aids	$0 copay
Hearing exam	$30 copay
Hearing exam	$50 copay (Out-of-Network)

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Inpatient Hospital Coverage

40% per stay (Out-of-Network)
$305 per day for days 1 through 7 $0 per day for days 8 through 90

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Medical Equipment/Supplies

Diabetes supplies	40% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	40% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$250 per day for days 1 through 7 $0 per day for days 8 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$10,000 In and Out-of-network $4,900 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

40% coinsurance per visit (Out-of-Network)
$0-285 copay per visit

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Package #1

Deductible
Monthly Premium	$7.00

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Package #2

Deductible
Monthly Premium	$31.00

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Package #3

Deductible
Monthly Premium	$55.00

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Preventive Care

40% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	$0 copay
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
50% per stay (Out-of-Network)

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Amerivantage Classic Plus (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.