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 Benefit | Memorial 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 Facility | Days 1–20: $0 copay per day
Days 21–100: $160 copay per day
(OON–40%) |
| Durable Medical Equipment | 20% 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 Drugs | 27% 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
Rx | After 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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