Go Back
H5828 - 008 - 0
(3.5 / 5)
Amerivantage Balance Plus (HMO)is a Medicare Advantage (Part C) Plan by AMERIGROUP Community Care.
This page features plan details for 2023 Amerivantage Balance Plus (HMO)H5828 – 008 – 0 available in Tennessee.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
2024 Wellpoint Extra Help (HMO) H5828 - 008 - 0
Locations
Amerivantage Balance Plus (HMO)is offered in the following locations.
Anderson County, Tennessee
Bedford County, Tennessee
Benton County, Tennessee
Click to see more locations
Plan Overview
Amerivantage Balance Plus (HMO)offers the following coverage and cost-sharing.
| Insurer: | AMERIGROUP Community Care |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Amerivantage Balance Plus (HMO)?
Premium Breakdown
Amerivantage Balance Plus (HMO)has a monthly premium of $9.30. This amount includes your Part C and D premiums but does not include your Part B premium.The following is a breakdown of your monthly premium with Part B costs included.
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $9.30 | $0.00 | $174.20 |
Please Note:
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Amerivantage Balance Plus (HMO)provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $505.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $9.30 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $505.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Amerivantage Balance Plus (HMO)also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Endodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $90-200 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $0-90 copay (authorization required) (referral not required) |
| Lab services: | $0-10 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $50-90 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $25 copay per visit (authorization required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $0-25 copay (authorization required) (referral not required) |
| Routine foot care: | $0 copay (no limits) (authorization required) (referral not required) |
Ground ambulance
| $235 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Hearing aids: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Hearing exam: | $25 copay (authorization required) (referral not required) |
Hospital coverage (inpatient)
| $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $0-275 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $4,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $260 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $25 copay (authorization required) (referral not required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $25 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $25 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| $0 copay (limits may apply) (authorization not required) (referral not required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $6.00 |
| Preventive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $27.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $27.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $27.00 |
| Eyewear: | Deductible: | N/A |
Package #3
| Preventive dental: | Monthly Premium: | $49.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $49.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $49.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Amerivantage Balance Plus (HMO)?
Table of Contents
Get Help Enrolling
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
SMID: MULTIPLAN_HCIHNDOGMED01_M
Factsonmedicare.com is a free-to-use informational website by Dog Media Solutions LLC. All insurance agents and enrollment platforms linked to this site have their own terms and conditions.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B Premium give-back is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
All plan-related information on this site is from CMS.gov and Medicare.gov.We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.
HealthCompare Insurance Services does not offer every plan available in your area. Currently we represent 18 organizations, which offers 52,101 products in your area.
We do not feature every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Enrollment is offered through our partners including HealthCompare Insurance Services Please contactMedicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
HealthCompare Insurance Services represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.
Medicare has neither approved nor endorsed any information on this site.
© All rights reserved | About | Contact | Legal and Privacy
