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Compare Medicare Advantage Plans

Use this chart to compare Memorial Hermann Advantage plans side by side or call our representatives at (866) 350-2715 (TTY 711) for assistance. They can walk you through the differences between Memorial Hermann Advantage HMO and Memorial Hermann Advantage PPO so you can decide which one is best for your medical needs and budget.



Plan BenefitMemorial Hermann
Advantage HMO
Memorial Hermann
Advantage PPO
Monthly Plan PremiumYou pay nothingYou pay $25 per month. In addition, you must keep paying your Medicare B premium.
DeductibleNo deductibleNo deductible
Maximum Out-of-Pocket Responsibility (does not include prescription drugs)You pay no more than $6,700 annuallyYou pay no more than $6,700 annually for services you receive from In-Network providers. You pay no more than $9,500 annually for services you receive from any provider. Your limit for services received from In-Network providers will count toward this limit.
Inpatient Hospital CoverageYou pay $250 per day for days 1 through 5. You pay nothing for days 6 through 90.In-Network:
You pay $300 per day for days 1 through 5.
You pay nothing for days 6 through 90.


Out-of-Network:
You pay 40% coinsurance for days 1 through 90.

Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.
Outpatient Hospital CoverageYou pay $300 for each Medicare-covered outpatient hospital facility visit.You pay $450 for each Medicare-covered outpatient hospital facility visit.
Doctors VisitsPrimary Care Physician Visit: You pay $5 per visit. // Specialist Visit: You pay $50 per visit.Primary Care Physician Visit: In-Network: You pay $5 per visit. // Out-of-Network: You pay 40% coinsurance.

Specialist Visit: In-Network: You pay $50 per visit. // Out-of-Network: You pay 40% coinsurance.

Cost share may apply for Part B injectables. For detailed information regarding additional cost shares for the other covered in office procedures/services provided by the Physician/Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. Please note: Cost to visit  non-participating providers is based on the Medicare allowable.
Preventive CareYou pay nothingIn-Network: You pay nothing.

Out-of-Network: You pay 40% coinsurance.

Any additional preventive services approved by Medicare during the contract year will be covered. For Colorectal Cancer Screenings, please note that a colonoscopy or sigmoidoscopy conducted for polyp removal or biopsy is a surgical procedure subject to the outpatient surgery cost sharing described later in this benefit grid.

Emergency CareYou pay $80 per visitIn-Network or  Out-of-Network: You pay $80 per visit.

If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care.
Urgently Needed ServicesYou pay $35 per visitIn-Network or Out-of-Network: You pay $35 per visit.
Diagnostic
Services/Labs/Imaging

You pay nothing for Blood Services (Transfusions)

You pay $75 per test for Non-Radiologic Diagnostic Procedures/Tests

You pay $200 per test for Diagnostic Radiology Services (MRI, CT, PET). Prior authorization required.

You pay $5 per Lab Service

You pay $25 per session for Therapeutic Radiology Services (Radiation)

You pay $10 per x-ray for Outpatient X-rays

Blood Services: In-Network: You pay nothing per test. Out-of-Network: You pay 40% coinsurance.

Non-radiologic diagnostic procedures/tests: In-Network: You pay $75 per test/procedure. Prior Authorization required. // Out-of-Network: You pay 40% coinsurance.

Diagnostic radiology services (MRI, CT, PET): In-Network: You pay $250 per test. Prior Authorization required. // Out-of-Network: You pay 40% coinsurance.

Lab services: In-Network: You pay $10 per lab service. // Out-of-Network:  
You pay 40% coinsurance.

Therapeutic radiology services (radiation): In-Network: You pay $25 per session. // Out-of-Network: You pay 40% coinsurance.

Outpatient X-rays: In-Network: You pay $10 per X-ray. // Out-of-Network: You pay 40% coinsurance.

Hearing Services

Basic hearing and balance exam performed by a primary care doctor: $5

Hearing to diagnose and treat hearing and balance issues: You pay $50

Annual hearing exam: You pay $50

Hearing Aid(s) per year: $400 annual benefit to go towards the purchase of hearing aids

Basic hearing and balance exam performed by a primary care doctor: In-Network:  You pay $5 // Out-of-Network: You pay 40% coinsurance

Hearing exam to diagnose and treat hearing and balance issues: In-Network:  You pay $50 // Out-of-Network: You pay 40% coinsurance

Annual Hearing Exam: In-Network: You pay $10 // Out-of-Network: You pay 40% coinsurance

Hearing Aid(s) per year: $250 annual benefit towards the purchase of hearing aids for  In-Network or Out-of-Network.
Dental ServicesLimited dental services (does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

Comprehensive Services: You pay $75

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. 

We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.

Prior Authorization required.
Limited dental services  
(this does not include services in connection with

care,treatment, filling, removal, or replacement of teeth).

Comprehensive Services: You pay $150

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. 

We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.

Prior Authorization required.
Vision ServicesExam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing

Routine Eye Exam Performed by Optician/Optometrist/Ophthalmologist: You pay $50

Eyewear per year (Contact Lenses,  Eyeglasses (frames and lenses)): $200 annual benefit to go towards the purchase of eye-wear and contacts.
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-Network: You pay nothing. // Out-of-Network: You pay 40% coinsurance.

Routine Eye Exam Performed by Optician/Optometrist/Ophthalmologist: In-Network:
You pay $50 // Out-of-Network: You pay 40% coinsurance

Eyewear per year (Contact Lenses, Eyeglasses (frames and lenses)): $150 annual benefit towards the purchase of eye-wear and contacts In-Network or Out-of-Network.
Skilled Nursing FacilityYou pay nothing for days 1 through 20.

You pay $100 per day for days 21 through 100.

Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period.

Prior Authorization required.
In-Network: You pay nothing for days 1 through 20. You pay $150 per day for days 21 through 100.

Out-of-Network: You pay 40% coinsurance for days 1-100.

Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period. Prior Authorization required.
Rehabilitation ServicesCardiac (heart) Rehab Services:
You pay $25 per visit. Prior Authorization required for cardiac rehabilitation services.

Pulmonary Services:
You pay $25 per visit.

Occupational Therapy Visit: You pay $25 per visit.

Physical Therapy and Speech and Language Therapy Visit: You pay $25 per visit.
Cardiac (heart) Rehab Services: In-Network: You pay $25 per visit // Out-of-Network: You pay 40% coinsurance. Prior Authorization required for cardiac rehabilitation.

Pulmonary Services: In-Network: You pay $25 per visit // Out-of-Network: You pay 40% coinsurance.

Occupational Therapy Visit: In-Network: You pay $25 per visit // Out-of-Network: You pay 40% coinsurance.

Physical Therapy and Speech and Language Therapy Visit: In-Network: You pay $25 per visit //
Out-of-Network: You pay 40% coinsurance.
AmbulanceYou pay $250 per one-way tripIn-Network and Out-of-Network: You pay $300 copay per one-way trip
TransportationMemorial Hermann Advantage HMO does not offer transportation services.Memorial Hermann Advantage PPO does not offer transportation services.
Medicare Part B DrugsFor Part B drugs such as chemotherapy drugs:  You pay 20% coinsurance.

Other Part B Drugs: You pay 20% coinsurance.
For Part B drugs such as chemotherapy drugs:  In-Network: You pay 20% coinsurance. // Out-of-Network: You pay 40% coinsurance.

Other Part B Drugs: In-Network: You pay 20% coinsurance. // Out-of-Network: You pay 40% coinsurance.
Foot Care (Podiatry Services)You pay $25. Foot exams and treatment Routine Foot Care Limitations may apply.

In-Network: You pay $25.

Out-of-Network: You pay 40% coinsurance.

Foot exams and treatment Routine Foot Care Limitations may apply.
Durable Medicare Equipment/SuppliesYou pay 20% coinsurance. Prior Authorization required for items over $1,000.In-Network: You pay 20% coinsurance.

Out-of-Network: You pay 40% coinsurance.

Prior Authorization required for items over $1,000.
Wellness Programs (e.g. Fitness)Silver&Fit® Program: You pay nothing. Memorial Hermann Advantage offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more.

24 Hour Nurse Line:  You pay nothing.
Silver& Fit Program: You pay nothing.

24 Hour Nurse Line: You pay nothing.

Memorial Hermann Advantage offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more at no cost to you.
Part B
Prescription Drug Coverage
Memorial Hermann
Advantage HMO
Memorial Hermann
Advantage PPO
All Part B Drugs Including
Chemotherapy
20% coinsurance20% coinsurance (OON–40%)
Part D
Prescription Drug Coverage
Both Memorial Hermann Advantage HMO & Memorial Hermann Advantage PPO
Deductible$300 Deductible applies for Tiers 4-5
Initial Coverage Limit$3,750
Tier 1: Preferred Generic

HMO: $2.00 for One-Month Supply // $4.00 for Two-Month Supply // $5.00 for Three-Month Supply

PPO: $5.00 for One-Month Supply // $10.00 for Two-Month Supply // $12.50 for Three-Month Supply

Tier 2: Generic$15.00 for One-Month Supply // $30.00 for Two-Month Supply // $37.50 for Three-Month Supply
Tier 3: Preferred Brand$45.00 for One-Month Supply // $90.00 for Two-Month Supply // $112.50 for Three-Month Supply
Tier 4: Non-Preferred Brand$99.00 for One-Month Supply // $198.00 for Two-Month Supply // $247.50 for Three-Month Supply
Tier 5: Specialty Tier Drugs27% for One-Month Supply // Not available for Two-Month Supply // Not available for Three-Month Supply
Mail Order Availability

 

Tier

One-Month Supply

Two-Month Supply

Three-Month Supply

Tier 1 (Preferred Generic)

HMO: $2.00

 PPO: $5.00

HMO: $4.00

PPO: $10.00

HMO: $4.00

PPO: $10.00

Tier 2 (Generic)

$15.00

$30.00

$30.00

Tier 3 (Preferred Brand)

$45.00

$90.00

$90.00

Tier 4 (Non-Preferred Brand)

$90.00

$198.00

$198.00

Tier 5 (Specialty)

27%

Not available

Not available

 

 If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
Coverage Gap
Most Medicare plans have a coverage gap (also called the “donut hole”).  This means there’s a temporary change in what you will pay for your drugs.  The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750.  After you enter the coverage gap, you pay 35% of the price for brand name drugs (plus a portion of the dispensing fee) and 44% of the price for generic drugs.  Not everyone will enter the coverage gap.
Catastrophic Coverage RxAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the cost, or $3.35 copay for generic or a preferred multi-source drug (including brand drugs treated as generic) and a $8.35 copay for all other drugs.

Memorial Hermann Advantage HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

Memorial Hermann Advantage PPO is provided by Memorial Hermann Health Insurance Company, a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

*You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.


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