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Select HMO Plan

The IU Health Plans Select HMO delivers extra benefits, such as enhanced dental and vision coverage, but does not include prescription drug coverage. See below for details about this plan option.

IU Health Plans Medicare Select HMO Details

Cost: $0

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Medicare-Covered Benefit In-Network
Annual Monthly Premium Medical Deductible $0
Member Maximum Out-of-Pocket Medical Cost
Out-of-Pocket Cost Protection $4,850
Annual Maximum Out-of-Pocket Limit No limit
Inpatient/Home Health Care
Inpatient-Hospital/Mental Health $260 - days 1-7, $0 - days 8-90 IP Hosp.
Skilled Nursing (No hospital stay required) $0 - days 1-20, $160 - days 21/100
Home Health $0
Outpatient Care / Services / Supplies
Primary Care Physician $0
Specialist $30
Chiropractor $20
Podiatry $15
Outpatient Surgery $285
Ambulance $225
Emergency $65
Urgent Care $50
Durable Medical Equipment 20%
Diabetic Supplies $0
Diagnostic Tests/Lab $10
X-rays/Therapeutic Radiology $25
Diagnostic Radiology $135
Part B Covered Drugs 20%
Preventive Screenings $0
Annual Physical Exam $0
Additional Benefits and Wellness Programs
Fitness Center Membership up to $200 reimbursement/yr.
Preventive Dental $10
Routine Vision Exam $0
Eyeglasses (lenses/frames) $40/every two years
Part D Prescription Drugs
Annual Prescription Deductible $0
Tier 1 (Preferred Generic) Not covered
Tier 2 (Non-preferred Generic) Not covered
Tier 3 (Preferred Brand) Not covered
Tier 4 (Non-preferred Brand) Not covered
Tier 5 (Specialty) Not covered
Coverage Gap after $3,310 paid by plan/member until member out-of-pocket is reached $4,850 Not covered

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. H7220_IUHMA16104 CMS Approved 10/23/2015