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Medicare Advantage 2018

Memorial Hermann Advantage PPO Plan

The Memorial Hermann Advantage PPO plan is a Preferred Provider Organization (PPO) that offers the same health coverage benefits as Original Medicare, plus enhanced benefits to individuals who live in Harris, Fort Bend or Montgomery counties in Texas. The plan also covers both in-network and out-of-network Memorial Hermann Advantage providers.

That means you'll most likely pay less if you use doctors, hospitals and other health care providers that are within the Memorial Hermann Advantage PPO Network. You can still go to other health care providers outside of the plan network, but your coverage costs may be more outside the network.

Benefits of Memorial Hermann Advantage PPO

The Memorial Hermann Advantage PPO plan offers the same benefits covered under Original Medicare, plus enhanced benefits like:

$0 monthly premium on our HMO plan
PPO plans are also available for a monthly premium of $25.

No referrals needed to see any specialist
Gain access to our full range of specialists without a referral from your primary care provider.

National/worldwide urgent care and emergency coverage
Travel with confidence knowing that Memorial Hermann Advantage plans have you covered no matter where you are.

Prescription drug coverage (Part D)
Control drug costs with low copays for generics and name-brands, along with access to convenient mail delivery services.

Vision and hearing benefits
Get annual hearing and eye exam coverage plus $250 toward hearing aids every year.

Maximum out-of-pocket costs
Limit the annual financial liability of your healthcare costs.

Preventive screenings and services at no additional cost
Avoid major medical issues with no-cost preventive screenings for glaucoma, prostate cancer, breast cancer and more.

Fitness benefits and incentives
Enjoy a range of incentives and benefits including no-cost memberships at local fitness centers like the YMCA. Learn more >

Access to a vast network of hospitals and physicians
Serving Greater Houston with 17 hospitals, numerous specialty institutes and more than 3,000 physicians.

See the chart below for some of the costs associated with the Memorial Hermann Advantage PPO plan.



Plan BenefitMemorial Hermann
Advantage PPO
Monthly Plan PremiumYou pay $25 per month. In addition, you must keep paying your Medicare B premium.
DeductibleNo deductible
Maximum Out-of-Pocket Responsibility 
(does not include prescription drugs)
You 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 CoverageIn-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 $450 for each Medicare-covered outpatient hospital facility visit.
Doctors VisitsPrimary 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.
Preventative CareIn-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 CareIn-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 ServicesIn-Network or Out-of-Network: You pay $35 per visit.
Diagnostic
Services/Labs/Imaging

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 ServicesBasic 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 (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): 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.
Mental Health Services (including inpatient)Inpatient Services 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. Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.

Outpatient Services: Outpatient group therapy visit: In-Network: You pay $40 // Out-of-Network: You pay 40% coinsurance

Outpatient individual therapy visit: In-Network: You pay $40 // Out-of-Network: You pay 40% coinsurance. Outpatient individual therapy visit corresponds to total cost for each Medicare-covered individual therapy visit provided by a non-physician.
Skilled Nursing FacilityIn-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: 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.
Ambulance

In-Network or Out-of-Network: You pay $300 copay per one-way trip

TransportationMemorial Hermann Advantage PPO does not offer transportation services.
Medicare Part B Drugs 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)

In-Network: You pay $25.

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

Foot exams and treatment Routine Foot Care Limitations may apply.
Durable Medical Equipment/SuppliesIn-Network: You pay 20% coinsurance.

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

Prior Authorization required for items over $1,000.
Wellness ProgramsSilver& 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.
Initial Coverage – Standard Retail  Cost-Sharing
(After you pay  your deductible,  if applicable)
Memorial Hermann
Advantage PPO
Deductible$300 Deductible applies to Tiers 4-5
Initial Coverage Limit$3,750
Tier 1: Preferred Generic$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
Initial Coverage: Standard Mail Order Cost-Sharing
(After you pay your deductible, if applicable)

 

Tier

One-Month Supply

Two-Month Supply

Three-Month Supply

Tier 1 (Preferred Generic)

$5.00

$10.00

$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 drug plans have a coverage gap (also call the “donut hole”).  This means that 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.

What to Consider Before Enrolling in a Memorial Hermann Advantage PPO Plan

  • You cannot enroll in a Medicare Advantage plan if you are not already enrolled in Medicare Part A and Part B. To enroll in original Medicare, visit the Social Security Administration’s website, medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website).
  • In order to be eligible for a Memorial Hermann Advantage PPO plan, you must live within the Harris, Fort Bend or Montgomery counties in Texas.
  • Is your current doctor covered in the Memorial Hermann Advantage PPO plan to help lower the cost of coverage? View a list of Memorial Hermann Advantage PPO providers, also called the Memorial Hermann Advantage PPO Provider Directory.
  • Compare Medicare Advantage plans. Use our plan comparison page to view Memorial Hermann Advantage plans side by side and choose which one best meets your health and financial needs.

Disclaimer Information:

*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.

Medicare beneficiaries may also enroll in a Memorial Hermann Advantage plan through CMS Medicare Online Enrollment Center located at medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)


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