| Plan Benefit | Memorial Hermann
Advantage PPO |
|---|
| Monthly Plan Premium | You pay $25 per month. In addition, you must keep paying your Medicare B premium. |
| Deductible | No 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 Coverage | 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 Coverage | You pay $450 for each Medicare-covered outpatient hospital facility visit. |
| Doctors Visits | 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. |
| Preventative Care | In-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 Care | In-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 Services | In-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 Services | 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 Services | 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 Services | 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. |
| 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 Facility | 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 Services | 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. |
| Ambulance | In-Network or
Out-of-Network: You pay $300 copay
per one-way trip |
| Transportation | Memorial 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/Supplies | In-Network: You pay 20% coinsurance.
Out-of-Network: You pay 40% coinsurance.
Prior Authorization required for items over $1,000. |
| Wellness Programs | 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. |
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 Drugs | 27% 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
Rx | After 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. |