Summary of Benefts 2020 - Virginia Premier Advantage Gold (HMO) H9877-002 Virginia Premier Advantage Platinum (HMO) H9877-003
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Summary of Benefts 2020
Virginia Premier Advantage Gold (HMO) H9877-002
Virginia Premier Advantage Platinum (HMO) H9877-003
This Summary of Benefts includes service areas in
Central Virginia and Eastern Virginia
H9877_0719-SBGP20-800073_M F&U Date - 08/26/20192020 Central Virginia Service Area
Virginia Premier Advantage Gold and Advantage Platinum
Service Area – 26 cities/counties
Amelia, Brunswick, Caroline, Charles City, Charlotte, Chesterfeld, Colonial Heights City, Cumberland, Dinwiddie,
Goochland, Halifax, Hanover, Henrico, Hopewell City, King and Queen, King William, Louisa, Lunenburg,
Mecklenburg, New Kent, Nottoway, Petersburg City, Powhatan, Prince George, Richmond City, and Sussex
2020 Eastern Virginia Service Area
Virginia Premier Advantage Gold and Advantage Platinum
Service Area – 21 cities/counties
Chesapeake City, Emporia City, Essex, Franklin City, Gloucester, Greensville, Hampton City, Isle of Wight,
James City, Mathews, Middlesex, Newport News City, Norfolk City, Poquoson City, Portsmouth City,
Southampton, Suffolk City, Surry, Virginia Beach City, Williamsburg City, and York
1Let’s talk about Virginia Premier Advantage Gold
(HMO) and Advantage Platinum (HMO) Plans
(H9877-002 and H9877-003)
This summary will let you fnd out more about our Gold and Platinum plans including the medical and drug
services they cover.
Virginia Premier Advantage Gold and Advantage Platinum are Medicare Advantage HMO plans with a Medicare
contract. Enrollment in the plans depends on contract renewal.
The beneft information in this document is a summary of what we cover and what you pay. It does not list
every service we cover or every limitation or exclusion from our plan. To get a complete list of services we
cover, please call our Member Services department to request a copy of the Evidence of Coverage or visit us
online at VirginiaPremier.com.
To be eligible for our HMO plans: How to contact us:
To join Virginia Premier Medicare Advantage Gold If you are not a member of our plan, please contact
(HMO) or Advantage Platinum (HMO), you must us toll-free at 1-833-280-1216 (TTY: 711) for more
be entitled to Medicare Part A, be enrolled in information. You will be connected with a licensed
Medicare Part B and live in the service area of our Medicare Beneft Advisor.
plans. Please see the map of our service area on
the inside cover of this booklet. If you are a member of our plan, please call us
toll-free at 1-877-739-1370 (TTY: 711) to speak
Note: As a member you must select an in-network to a Medicare Benefts Representative. Our
doctor to act as your Primary Care Provider (PCP). representatives are available 7 days a week, 8 am
However, you can see one of our Specialist to 8 pm October 1 through March 31. From April 1
doctors without a referral from your PCP. We do through September 30, they are available Monday
encourage all of our members to seek Specialist through Friday 8 am to 8 pm. On certain holidays
referrals with their PCP. and weekends from April 1 through September 30,
you call will be handled by our automated phone
system.
Visit our web site at VirginiaPremier.com.
What doctors and hospitals you can use:
We have a network of doctors, hospitals, and other providers. If you use providers that are not in our network,
the plan may not pay for these services.
You can see our plan’s provider directory and view our prescription drug formulary on our website at
VirginiaPremier.com.
This document is available in other formats such as large print and audio.
2To fnd out more about the coverage and costs of Original Medicare, look in the current “Medicare & You”
handbook. View it online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week. TTY users should call 1-877-486-2048.
Virginia Premier is an HMO and HMO SNP organization with a Medicare contract. Enrollment in Virginia Premier
depends on contract renewal. This information is not a complete description of benefts. Contact the plan for
more information. Virginia Premier Health Plan, Inc. is a fully-owned subsidiary of VCU Health. Other physicians
and providers are available in our network.
Monthly Premium, Deductible and Out-of-Pocket Limits
Medicare Advantage Medicare Advantage
Premiums and Benefts
Gold (HMO) Platinum (HMO)
Monthly Premium $0 $29
Medical Deductible $0 $0
Pharmacy (PART D) $250 for Tier 3, Tier 4 and Tier 5 $100 for Tier 3, Tier 4 and Tier 5
Prescription Drug $0 for Tier 1 and Tier 2 $0 for Tier 1 and Tier 2
Deductible
Out-of-pocket Maximum $5,900 annually. After you reach this $5,900 annually. After you reach this
(Does not include amount through co-pays, coinsurance amount through co-pays, coinsurance
prescription drugs) and other medical services we will and other medical services we will
pay the full cost of covered services pay the full cost of covered services
for the rest of the year. for the rest of the year.
How can we charge a $0 or very low premium? Virginia Premier is reimbursed each month from the Centers
for Medicare & Medicaid Services (CMS) for our covered members. We become your insurer of Medicare
benefts in place of CMS and Original Medicare.
Covered Medical and Hospital Benefts
Inpatient Hospital1 $300 co-pay for days 1 through 5 $250 co-pay for days 1 through 5
$0 co-pay for days 6 and beyond $0 co-pay for days 6 and beyond
Outpatient Hospital1 Outpatient Hospital: $325 co-pay Outpatient Hospital: $300 co-pay
Ambulatory Surgical Center: Ambulatory Surgical Center:
$275 co-pay $250 co-pay
Doctor Visits Primary care provider: $0 co-pay Primary care provider: $0 co-pay
Specialists: $45 co-pay Specialists: $35 co-pay
Preventive Care Our plan covers many preventive Our plan covers many preventive
Screenings services at $0 co-pay when you get services at $0 co-pay when you get
services with an in-network provider. services with an in-network provider.
Annual Physical Exam* $0 co-pay $0 co-pay
* If you receive either an annual wellness exam or annual physical exam you will receive a
$25 incentive just for getting the exam
3Emergency Care
Medicare Advantage Medicare Advantage
Beneft Category
Gold (HMO) Platinum (HMO)
Emergency Room $90 per visit $90 per visit
Note: If you are admitted to the Note: If you are admitted to the
hospital within 3 days, you do not hospital within 3 days, you do not
have to pay your share of the cost for have to pay your share of the cost for
the emergency room the emergency room
Worldwide Emergency Up to $50,000 per year Up to $50,000 per year
Care
Outpatient Care and Services
Diagnostic Services, Labs • Therapeutic radiology services: • Therapeutic radiology services:
and Imaging1 $60 $50
Note: Cost sharing will vary • X-ray services: $45 • X-ray services: $35
depending on the service
and where it is given • Diagnostic radiology (CT, MRI, • Diagnostic radiology (CT, MRI,
etc.): $275-$325 depending on etc.): $250-$300 depending on
service location. service location
• Labs and testing: $15 • Labs and testing: $0
Hearing Services
Medicare-Covered Exams You pay $45 co-pay You pay $35 co-pay
to Diagnose and Treat
Hearing and Balance
Issues
Routine Hearing Exam You pay $0 for one routine hearing You pay $0 for one routine hearing
exam and ftting annually exam and ftting annually
Hearing Aid Allowance Up to $750 every 3 years for a hearing Up to $1,000 every 3 years for a
aid. Major discounts with our hearing hearing aid. Major discounts with
aid supplier. Extended warranty and 1 our hearing aid supplier. Extended
year of batteries. warranty and 1 year of batteries.
Dental
Routine Dental Services You pay $0 for 2 cleanings, 2 You pay $0 for 2 cleanings, 2
fuoride treatments, 2 exams, and 1 fuoride treatments, 2 exams, and 1
bitewing and 1 panoramic X-ray bitewing and 1 panoramic X-ray
every 3 years every 3 years
Comprehensive Dental 50% coinsurance for fllings, 50% coinsurance for fllings,
Services extractions, crowns, implants and extractions, crowns, implants and
bridges up to $1,000 per year bridges up to $1,000 per year
4Vision
Medicare Advantage Medicare Advantage
Beneft Category
Gold (HMO) Platinum (HMO)
Medicare-Covered Vision You pay $45 co-pay You pay $35 co-pay
Services
Routine Vision Care You pay $0 for 1 exam annually You pay $0 for 1 exam annually
Eyewear $150 allowance toward glasses/ $200 allowance toward glasses/
contacts annually contacts annually
Mental Health Services
Inpatient Stays1 You pay $300 per day for days 1-5 You pay $250 per day for days 1-5
You pay $0 days 6-150 You pay $0 days 6-150
Outpatient Group Therapy/ You pay $40 co-pay You pay $30 co-pay
Individual Therapy Visit1
Rehabilitative Services
Cardiac Rehabilitation Medicare-covered $50 co-pay Medicare-covered $50 co-pay
Services1
Intensive Cardiac Medicare-covered $100 co-pay Medicare-covered $100 co-pay
Rehabilitation Services1
Pulmonary Rehabilitation Medicare-covered $30 co-pay Medicare-covered $30 co-pay
Services1
Supervised Exercise Medicare-covered $30 co-pay Medicare-covered $30 co-pay
Therapy (SET)
for Symptomatic
Peripheral Artery Disease
(PAD)1
Skilled Nursing Facility You pay $0 days 1-20 You pay $0 days 1-20
(SNF)1 You pay $160 per day for days 21-100 You pay $140 per day for days 21-100
Physical Therapy/ You pay $40 co-pay You pay $35 co-pay
Occupational Therapy/
Speech Language
Pathology1
5Additional Benefts
Medicare Advantage Medicare Advantage
Beneft Category
Gold (HMO) Platinum (HMO)
Ambulance Services - You pay $275 co-pay You pay $250 co-pay
Ground 2
Ambulance Services - Air 2 20% coinsurance 20% coinsurance
Transportation1 $0 co-pay for 6 one-way trips or 3 $0 co-pay for 4 one-way trips or 2
round trips per year round trips per year
Medicare Part B Drugs1 You pay 20% of the cost for You pay 20% of the cost for
chemotherapy drugs chemotherapy drugs
You pay 20% of the cost for other You pay 20% of the cost for other
Part B drugs Part B drugs
Footcare (Podiatry
Services)
Medicare-Covered You pay $45 co-pay You pay $35 co-pay
Services1
Routine Footcare You pay $20 co-pay per visit, 4 visits You pay $20 co-pay per visit, 8 visits
annually annually
Durable Medical You pay 20% of the cost You pay 20% of the cost
Equipment and Supplies1
Fitness Beneft Fitness center membership Fitness center membership
You pay nothing at participating You pay nothing at participating
facilities facilities
Chiropractor Routine care not covered $0 co-pay for 6 routine care visits
$20 co-pay for Medicare-covered annually
services $20 co-pay for Medicare-covered
services
Over-the-Counter (OTC) $50 mail order allowance per quarter $60 mail order allowance per quarter
Drug Beneft (does not carry over) (does not carry over)
Meal Beneft Meals ordered by Physician or Plan Meals ordered by Physician or Plan
Care Coordinator after discharge from Care Coordinator after discharge from
inpatient or skilled nursing facility inpatient or skilled nursing facility
stay. Member receive up to 28 meals stay. Member receive up to 28 meals
(2 per day) for qualifed discharge. (2 per day) for qualifed discharge.
1 You do not need a referral to receive covered services from providers. However, certain procedures, services and
drugs marked with a 1 may need approval in advance from your plan. This is called “prior authorization.” Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from
our plan. The provider/pharmacy network may change at any time. You will receive notice when necessary.
2 Authorization required for non-emergency services
6Outpatient Prescription Drugs
Medicare Advantage Medicare Advantage
Beneft Category
Gold (HMO) Platinum (HMO)
Pharmacy Deductible $250 annual deductible for Tier 3, $100 annual deductible for Tier 3,
Tier 4, and Tier 5 Tier 4, and Tier 5
$0 for Tier 1 and Tier 2 $0 for Tier 1 and Tier 2
Initial Coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the total
drug costs paid by both you and our plan.
Outpatient Prescription Drugs – Initial Coverage
Retail Rx 31-day Retail Rx 90-day
Advantage Gold Plan supply supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay $15
Tier 3: Preferred Brand You pay $47 You pay $141 You pay $117.50
Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay $250
Tier 5: Specialty Tier You pay 28% Not offered Not offered
Retail Rx 31-day Retail Rx 90-day
Advantage Platinum Plan supply supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay $12
Tier 3: Preferred Brand You pay $47 You pay $141 You pay $117.50
Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay $250
Tier 5: Specialty Tier You pay 31% Not offered Not offered
Note: Specialty drugs are limited to a 31-day supply. Cost sharing may change if you qualify for "Extra Help."
To fnd out if you qualify, please contact the Social Security Offce at 1-800-772-1213, Monday - Friday 7 am
to 7 pm. TTY users should call 1-800-325-0778. For more information on the additional pharmacy-specifc cost
sharing and the phases of the beneft, please call us or access our “Evidence of Coverage” online.
If you reside in a long-term care facility, you pay the same as a standard retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network facility.
7Coverage Gap
Most Medicare drug plans have a coverage gap (also called the “donut hole”.) This means that there’s a
temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug costs
(including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s costs for covered brand name drugs until your
costs total $6,350 which is the end of the coverage gap. Not everyone will enter the coverage gap.
Coverage Gap
Retail Rx 31-day Retail Rx 90-day
Advantage Gold Plan supply supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay $15
Retail Rx 31-day Retail Rx 90-day
Advantage Platinum Plan supply supply
Mail Order 90-day
Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2
Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay $12
For all other formulary drugs, after you enter the coverage gap, you pay 25% of the plan's cost for covered
brand name drugs, until your costs total $6,350, which is the end of the coverage gap.
Catastrophic Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $6,350 you pay $3.60 co-pay for those generic or preferred generic with a retail
price under $72 and 5% of the cost for those with a retail price greater than $72. For brand-name drugs you
pay $8.95 co-pay for those drugs with a retail price under $179 and 5% coinsurance for those with a retail
price over $179.
Find Your Doctors, Hospitals, Pharmacies and Research Our
Drug Formulary
Providers/Pharmacies
You can easily fnd a list of our providers online. Visit VirginiaPremier.com to fnd the most up-to-date list
of our providers, including doctors, hospitals, urgent care centers and pharmacies in our network. You can
always call one of our Medicare Member Services Representatives at 1-877-739-1370 (TTY: 711) to ask about
providers and facilities in our network. From October 1 to March 31, we are open daily from 8 am to 8 pm,
7 days a week. From April 1 through September 30, we are open Monday through Friday, 8 am to 8 pm. On
certain holidays and weekends from April 1 through September 30, your call will be handled by our automated
phone system.
Formulary
You can check our full formulary online at VirginiaPremier.com or call one of our Medicare Member Services
Representatives at the number above. Medicare Beneft Advisors who are licensed sales representatives are
also available toll free at 1-833-280-1216.
8Notice of Non-Discrimination
Virginia Premier Health Plan, Inc. (Virginia Premier) complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Virginia Premier does not exclude people or treat them differently because of race, color,
national origin, age, disability, or sex.
Virginia Premier:
Provides free aids and services to people with disabilities to communicate
effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible
electronic formats, other formats)
Provides free language services to people whose primary language is not
English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Member Services at 1-877-739-1370, TTY: 711.
If you believe that Virginia Premier has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with:
Virginia Premier
Attn: Grievances & Appeals Manager
P.O. Box 5244
Richmond, VA 23220
1-877-739-1370, TTY: 711
Fax: 800-289-4970
grievancesandappeals@virginiapremier.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, the Grievances & Appeals Manager is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
H9877_0817-NND-600001 AI 08/25/2017
9Multi-Language Insert
Multi-Language Interpreter Services
ATTENTION: If you speak English, language assistance services, free of charge, are available
to you. Call 1-877-739-1370 (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-877-739-1370 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-877-739-1370 (TTY: 711) 번으로 전화해주십시오.
CHÚ Ý: Nếu bạn nói Tiếng Việt, chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho
bạn. Xin gọi số 1-877-739-1370 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-739-1370
(TTY: 711)。
1-877-739-1370 اتصل برقم. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان، إذا كنت تتحدث العربية:ملحوظة
.)711 :TTY( (الهاتف النصي
PAUNAWA: Kung nagsasalita ka ng Tagalog, may mga magagamit kang libreng serbisyo ng
tulong sa wika. Tumawag sa 1-877-739-1370 (TTY: 711).
با شماره. تسھیالت زبانی بصورت رایگان برای شما فراهم می باشد، اگر به زبان فارسی صحبت می کنید:توجه
.( تماس بگیریدTTY: 711) 1-877-739-1370
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡፡ ወደ ሚከተለው
ቁጥር ይደውሉ 1-877-739-1370 (መስማት ለተሳናቸው: 711).
آپ کے ليے مفت دستياب ہے۔، زبان سے متعلق اعانت کی خدمات، اگر آپ اردو بولتے ہيں تو:توجہ ديں
پر کال کريں۔1-877-739-1370 (TTY: 711)
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-877-739-1370 (ATS: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-877-739-1370 (линия TTY: 711).
ध्यान दें: यदद आप ह द
िं ी बोलते ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ।ैं
1-877-739-1370 (TTY: 711) पर कॉल करें ।
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-739-1370 (TTY: 711).
H9877_0817-MLI-500009 Accepted 08/20/2017
10মননোনযোগ দিনঃ আপদন যদি বোাংলোনে কথো বলনে পোনেন, েোহনল দনঃখেচোয় ভোষো সহোয়েো
পদেনষবো উপলব্ধ আনে। ফ োন করুন 1-877-739-1370 (TTY: 711)
YI LE: I balè u pot tila hop won ngim bod i kobol mahop i la hola wè ni hop won, u saa béé to
yom. Sébél 1-877-739-1370 (TTY: 711).
GENU NTI: Ọ buru na ina asu asusu Igbo, enyemaka na-ahazi asusu, bu n’efu, diri gi mgbe
niile. Kpoo nomba ndi a 1-877-739-1370 (TTY: 711).
AKIYESI: Bi o ba nsọ èdè Yorùbá, ọfé ni iranlọwọ lori èdè wa fun yin. Ẹ pe ẹrọ-ibanisọrọ yi
1-877-739-1370 (TTY: 711).
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