Key Terms to Know

  • COINSURANCE: If your Plan has a coinsurance you pay a percentage of the allowable billed charges for Covered Care and/or Services and/or Prescription Drugs.
  • COPAYMENT (COPAY): A set dollar amount that you may pay for Covered Care and Services, or Prescription Drugs each time you visit a Provider or Pharmacy.
  • COVERAGE GAP: A temporary limit on what most Medicare Part D Prescription Drug Plans or Medicare Advantage Prescription Drug Plans pay for Prescription Drug Costs. You might pay higher costs for brand-name and Generic Drugs.
  • DEDUCTIBLE: You pay the full cost for Medical/Health Services or Prescription Drugs until you reach the set amount before coverage begins.
  • DRUG TIERS: Your plan has five Tier cost-share levels for covered drugs in the Formulary. The Tier will specify your Copay (if any) for your Prescription Drug. This applies to all Plans that include Part D coverage.
  • EMERGENCY SERVICES: Inpatient and Outpatient Services that may evaluate and treat medical conditions that need immediate attention to prevent loss of life, loss of a limb or loss of function of a limb.
  • FORMULARY: A list of all Prescription Drugs covered by our Plan. The list includes the Tier and Copay information for the specific medication. This is for plans that include Part D coverage.
  • MONTHLY PREMIUM: The cost you pay monthly for the Plan Coverage, this is in addition to the costs of Part A/Part B payments that Medicare may require.
  • URGENT CARE: Medical services needed immediately as a result of unforeseen illness, injury or condition. These are not Emergency Services.
  • MAXIMUM OUT-OF-POCKET (MOOP): The maximum amount you will pay during the coverage year for Medical and Hospital Services that are covered under Part A and B.
  • TRUE OUT-OF-POCKET (TROOP): This is the maximum amount you would need to spend each year on medications covered by your Prescription Drug Plan before you reach the “catastrophic” level of coverage.

Coverage GAP Guide

STAGE 1 – You pay 100%
Deductible Stage

  • The amount you pay of your medication costs before your plan pays its share. Some plans do not have a deductible.

STAGE 2 – Shared costs with insurance company
Initial Coverage Stage

  • Both you and your insurance plan pay medication costs until the shared total equals $3,820
  • You’re generally responsible for the copays and coinsurance during the stage

STAGE 3 – Donut hole
Coverage gap stage

  • The coverage gap begins after you and your plan have spent $3,820 for covered drugs and ends when you have spent $5,100 for them. During this gap in prescription drug coverage, you’ll generally pay more for your drugs.
  • In this stage, you pay a maximum of 25 percent of the cost of brand name drugs.  You also receive some coverage for generic drugs that we do not cover in the coverage gap.  You pay no more than 37 percent of the cost of generic drugs and the plan pays the rest.
  • Any medication- related deductible, coinsurance, copayments, the discounts you receive on covered drugs and the amounts you pay in the coverage gap count toward the $5,100 limit.

STAGE 4 – Follows the coverage gap
Catastrophic coverage stage

  • Begins when you reach the $5,100 coverage gap limit
  • In this stage, you pay either 5 percent of your medication’s cost, or $3.40 for generic drugs or a drug that is treated as generic and $8.50 for all other drugs.

 

Key Terms to Know

  • COINSURANCE: If your Plan has a coinsurance you pay a percentage of the allowable billed charges for Covered Care and/or Services and/or Prescription Drugs.
  • COPAYMENT (COPAY): A set dollar amount that you may pay for Covered Care and Services, or Prescription Drugs each time you visit a Provider or Pharmacy.
  • COVERAGE GAP: A temporary limit on what most Medicare Part D Prescription Drug Plans or Medicare Advantage Prescription Drug Plans pay for Prescription Drug Costs. You might pay higher costs for brand-name and Generic Drugs.
  • DEDUCTIBLE: You pay the full cost for Medical/Health Services or Prescription Drugs until you reach the set amount before coverage begins.
  • DRUG TIERS: Your plan has five Tier cost-share levels for covered drugs in the Formulary. The Tier will specify your Copay (if any) for your Prescription Drug. This applies to all Plans that include Part D coverage.
  • EMERGENCY SERVICES: Inpatient and Outpatient Services that may evaluate and treat medical conditions that need immediate attention to prevent loss of life, loss of a limb or loss of function of a limb.
  • FORMULARY: A list of all Prescription Drugs covered by our Plan. The list includes the Tier and Copay information for the specific medication. This is for plans that include Part D coverage.
  • MONTHLY PREMIUM: The cost you pay monthly for the Plan Coverage, this is in addition to the costs of Part A/Part B payments that Medicare may require.
  • URGENT CARE: Medical services needed immediately as a result of unforeseen illness, injury or condition. These are not Emergency Services.
  • MAXIMUM OUT-OF-POCKET (MOOP): The maximum amount you will pay during the coverage year for Medical and Hospital Services that are covered under Part A and B.
  • TRUE OUT-OF-POCKET (TROOP): This is the maximum amount you would need to spend each year on medications covered by your Prescription Drug Plan before you reach the “catastrophic” level of coverage.

Coverage GAP Guide

STAGE 1 – You pay 100%
Deductible Stage

  • The amount you pay of your medication costs before your plan pays its share. Some plans do not have a deductible.

STAGE 2 – Shared costs with insurance company
Initial Coverage Stage

  • Both you and your insurance plan pay medication costs until the shared total equals $3,820
  • You’re generally responsible for the copays and coinsurance during the stage

STAGE 3 – Donut hole
Coverage gap stage

  • The coverage gap begins after you and your plan have spent $3,820 for covered drugs and ends when you have spent $5,100 for them. During this gap in prescription drug coverage, you’ll generally pay more for your drugs.
  • In this stage, you pay a maximum of 25 percent of the cost of brand name drugs.  You also receive some coverage for generic drugs that we do not cover in the coverage gap.  You pay no more than 37 percent of the cost of generic drugs and the plan pays the rest.
  • Any medication- related deductible, coinsurance, copayments, the discounts you receive on covered drugs and the amounts you pay in the coverage gap count toward the $5,100 limit.

STAGE 4 – Follows the coverage gap
Catastrophic coverage stage

  • Begins when you reach the $5,100 coverage gap limit
  • In this stage, you pay either 5 percent of your medication’s cost, or $3.40 for generic drugs or a drug that is treated as generic and $8.50 for all other drugs.

 

MMM of Florida, Inc. is an HMO plan with a Medicare contract. Enrollment in MMM of Florida depends on contract renewal. This information is not a complete description of benefits. Call 1-844-212-9858 (TTY: 1-833-523-2620) for more information. Every year, Medicare evaluates plans based on a 5-star rating system.  MMM of Florida, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. MMM of Florida, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-212-9858 (TTY:1-833-523-2620). MMM of Florida, Inc. konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-844-212-9858 (TTY:1-833-523-2620).

 

Latest website update: October 2018

H3293_2019 4006 0002 1