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Medicare Advantage 2017

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 plan premiums on HMO and PPO plans
Enjoy $0 monthly plan premiums as long as you continue to pay your Medicare Part B premium.

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.

Expand coverage with the Memorial Hermann Advantage Pack
For an additional monthly fee, you'll get benefits such as comprehensive dental coverage, expanded vision benefits, and access to chiropractic services. Learn more >

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



Plan BenefitMemorial Hermann
Advantage PPO
Monthly Plan Premium$0
Maximum Out-of-Pocket Limit$6,700 INN 
$9,500 Out-of-Network (OON)/combined
Inpatient Hospital$300 per day for days 1–5
$0 for days 6–90
Primary Care Provider Services$5 copay (OON–40%)
Physician Specialist Services$40 copay (OON–40%)
Ambulatory Surgical Center$225 copay (OON–40%)
Outpatient Hospital Services$225 copay (OON–40%)
Skilled Nursing FacilityDays 1–20: $0 copay per day
Days 21–100: $160 copay per day
(OON–40%)
Durable Medical Equipment20% coinsurance
(OON–40%)
Lab & Diagnostic Services$0 copay (OON

– 40%) for lab services

$10 copay (OON - 40% for procedures)

Outpatient X-Rays$15 copay (OON–40%)
Medicare-Covered Therapeutic
Radiological Services
$25 copay (OON–40%)
Medicare-Covered Diagnostic
Radiological Services
$300 copay (OON–40%) for high-end diagnostics such as CT Scan or MRI
Urgently Needed Care$40 copay
Emergency Care$75 copay
Home Health Care$0 copay (OON–40%)
Annual Preventive Services: Bone
Mass Measurement, Colorectal
Screening Exam, Pneumonia &
Flu Vaccine, Screening
Mammogram, Pap Smear & Pelvic
Exam, Prostate Screening
$0 copay (OON–40%)
Hearing Benefit**

Basic hearing and balance exam performed by a primary care provider: $0 copay (OON – 40%)


Hearing exam to diagnose and treat hearing and balance issue $40 copay (OON–40%)


$250 for hearing aids every
year, both ears combined (In-network/OON)
Vision Benefit$0 copay for one routine eye exam
per year performed by in-network Optician / Optometrist (OON

–40%)

$40 copay for routine eye exam performed by in-network Ophthalmologist (OON – 40%)

$50 for eyewear every year (In-network/OON)

Readmission Prevention Care***$10 copay
(OON–40%)
Part B
Prescription Drug Coverage
Memorial Hermann
Advantage PPO
All Part B Drugs Including
Chemotherapy
20% coinsurance (OON–40%)
Part D
Prescription Drug Coverage
Memorial Hermann
Advantage PPO
Deductible$300 Deductible applies to Tiers 4-5
Initial Coverage Limit$3,700
Tier 1: Preferred Generic$5 copay for 30-day supply
Tier 2: Non-preferred Generic$15 copay for 30-day supply
Tier 3: Preferred Brand$45 copay for 30-day supply
Tier 4: Non-Preferred Brand$99 copay for 30-day supply
Tier 5: Specialty Tier Drugs27% coinsurance for 30-day supply
Mail Order Availability

 

Tier

Mail Order Copay (90 day supply)

Tier 1 (Preferred Generic)

$10

Tier 2 (Non-Preferred Generic)

$30

Tier 3 (Preferred Brand)

$90

Tier 4 (Non-Preferred Brand)

$198

Tier 5 (Specialty)

Not available

 

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 $3,700.  
After you enter the coverage gap, you pay 40% of the price for brand name drugs pls a portion of the dispensing fee and 51% of the price for generic drugs.  Not everyone will enter the coverage gap.

 

Catastrophic Coverage RxAfter your total yearly drug costs reach $4,950, you will pay $3.30 for generic drugs and $8.25 for brand drugs or 5% coinsurance for these drugs, whichever amount is greater.

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.

**Plan maximum contribution for hearing aids is $250 every year, both ears combined.

***Memorial Hermann Advantage PPO will help cover the cost when non-skilled attendant care is authorized by a Care Manager.

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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