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Medicare Value HMO

Premium

$25

Per Month

Deductible

$0

Medical Deductible

Office Visit

$30

Co-Pay

Specialist Visit

$25

Co-Pay

Prescription Drugs (Part D) Coverage

Tier	Type	Deductible	Co-Pay
Tier 1	Preferred Generic	$0	$4 retail / $8 mail-order
Tier 2	Generic	$0	$10 retail / $20 mail-order
Tier 3	Preferred	$320	$45 retail / $90 mail-order
Tier 4	Non-Preferred	$320	$95 retail / $285 mail-order
Tier 5	Specialty	$320	26%

Tier 1 Preferred Generic
Deductible	$0
Co-Pay	$4 Retail / $8 Mail-Order
Tier 2 Generic
Deductible	$0
Co-Pay	$10 Retail / $20 Mail-Order
Tier 3 Preferred Brand
Deductible	$320
Co-Pay	$45 Retail / $90 Mail-Order
Tier 4 Non-Preferred Brand
Deductible	$320
Co-Pay	$95 Retail / $285 Mail-Order
Tier 5 Specialty
Deductible	$320
Co-Pay	26% / Not Available

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Helpful Links

Summary of Benefits
Evidence of Coverage
Additional Benefits

Additional Benefits

$45 Preventive Hearing Exam

You must see a TruHearing® provider to use this benefit. Other providers are available in our network. Please note, hearing aids purchased through other providers are not covered.

$0 Preventive Vision Exam

You must see a TruHearing® provider to use this benefit. Other providers are available in our network. Please note, hearing aids purchased through other providers are not covered.

$100 Eyewear Allowance

You must see a TruHearing® provider to use this benefit. Other providers are available in our network. Please note, hearing aids purchased through other providers are not covered.

$250 Dental Allowance

$150 Fitness / Weight Watchers / Safety Items / Over-the-counter Allowance

$350 Accupuncture / Fitness Tracker / Wig Allowance

Wig allowance only available if on chemotherapy

Plan Details

Monthly Plan Premium	$25
Medical Out of Pocket Maximum	$6,700
Inpatient Hospital	$225 per day for days 1-7, per admission $4,725 inpatient maximum per calendar year
Outpatient Surgery	$450
Skilled Nursing Facility	Days 1-20: $0 copay per day Days 21-50: $160 copay per day Days 51-100: $0 copay per day
Teladoc Virtual Doctor Visits	$30
Urgent Care	$50
Worldwide Emergency Room	$90
Ambulance	$175
Outpatient Rehabilitation (PA after visit 25)	$40
High Cost Imaging	$250
Lab Work / X-Rays	$25 Labs / $25 X-Rays
Durable Medical Equipment / Prosthetics	20% Coninsurance

Monthly Plan Premium
$25
Medical Out of Pocket Maximum
$6,700
Inpatient Hospital
$225 per day for days 1-7, per admission $4,725 inpatient maximum per calendar year
Outpatient Surgery
$450
Skilled Nursing Facility
Days 1-20: $0 copay per day Days 21-50: $160 copay per day Days 51-100: $0 copay per day
Teladoc Virtual Doctor Visits
$30
Urgent Care
$50
Worldwide Emergency Room
$90
Ambulance
$175
Outpatient Rehabilitation (PA after visit 25)
$40
High Cost Imaging
$250
Lab Work / X-Rays
$25 Labs / $25 X-Rays
Durable Medical Equipment / Prosthetics
20% Coninsurance

Medicare Value HMO

$25

$0

$30

$25

Prescription Drugs (Part D) Coverage

Questions?

Helpful Links

Additional Benefits

$45 Preventive Hearing Exam

$0 Preventive Vision Exam

$100 Eyewear Allowance

$250 Dental Allowance

$150 Fitness / Weight Watchers / Safety Items / Over-the-counter Allowance

$350 Accupuncture / Fitness Tracker / Wig Allowance

Plan Details

Medicare Value HMO

Prescription Drug (Part D) Coverage

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