Liberty Medicare Advantage (HMO C-SNP)
Medicare Advantage Health Plan Details
Chronic Condition (C-SNP)
Health insurance company offering plan: Liberty Medicare Advantage
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $0-$10 copay
Out-of-network: $0 copay
Emergency Room
$100 copay
Ambulance Coverage
In-network: $175 copay
Out-of-network: $175 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$275 copay
Out-of-network: $0-$275 copay
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$125 copay
Out-of-network: $0-$125 copay
Outpatient x-rays:
In-network: $10 copay
Out-of-network: $10 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$250 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Outpatient hospital coverage:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Rehabilitation Coverage
Occupational therapy services:
In-network: $25 copay
Out-of-network: $25 copay
Urgent Care Coverage
$100 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$217 per day for days 21-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $50 copay
Out-of-network: $50 copay
Outpatient individual therapy with a psychiatrist:
In-network: $50 copay
Out-of-network: $50 copay
Outpatient group therapy visits:
In-network: $50 copay
Out-of-network: $50 copay
Outpatient individual therapy visit:
In-network: $50 copay
Out-of-network: $50 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$35.00 copay (30-day supply)
$105.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$95.00 copay (30-day supply)
$285.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
33% coinsurance (90-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$30.00 copay (30-day supply)
$90.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$90.00 copay (30-day supply)
$270.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
33% coinsurance (90-day supply)
Additional Added Benefits
Plan Links
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