Plan ID: H2462-023

What You Need to Know:

  • HealthPartners Sanford Vital (Cost) is a Medicare Advantage Health Maintenance Organization Cost * 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 $40, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is no drug coverage.
  • The plan includes an out-of-pocket maximum of $3,400 per year (in-network).
  • HealthPartners Sanford Vital (Cost) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is no drug coverage.
  • This plan's Part D Initial Coverage Limit is .

$40

Monthly Premium

Medicare Plan Features
Monthly Premium: $39.70
Part C Premium: NULL
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$39.70 NULL NULL NULL NULL NULL NULL
Gap Coverage: NULL
Benchmark: NULL
Type of Medicare Health: NULL
Health Plan Type: Cost *
Similar Plan: H2462-024
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: NULL
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $3,400
Annual Deductible: no drug coverage
Annual Initial Coverage Limit ICL: NULL
Number of Members enrolled in this plan in Union, South Dakota: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members 4.5 out of 5 Stars. Insufficient data to rate this plan. 5 out of 5 Stars.
Plan Offers Mail Order: NULL
Plan Health Benefits
Total # of Formulary Drugs: NULL
Number of Members Enrolled in this Plan in Union, South Dakota: 26 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
NULL NULL NULL NULL
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
NULL NULL NULL NULL NULL NULL NULL
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)
NULL NULL NULL NULL NULL NULL NULL NULL NULL NULL

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