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Select Plus HMO Plan

The IU Health Plans Select Plus HMO offers medical benefits plus Part D prescription drug coverage for one premium. See below for details about this coverage option.

IU Health Plans Medicare Select Plus HMO Details

Cost: $42

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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
Inpatient/Home Health Care
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 $10
Outpatient Care / Services / Supplies
Primary Care Physician $10
Specialist $40
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) $6 - 30 day, $18 - 90 day
Tier 2 (Non-preferred Generic) $15 - 30 day, $44 - 90 day
Tier 3 (Preferred Brand) $45 - 30 day, $126 - 90 day
Tier 4 (Non-preferred Brand) $95 - 30 day, $266 - 90 day
Tier 5 (Specialty) 33% - 30 day
Coverage Gap after $3,310 paid by plan/member until member out-of-pocket is reached $4,850 Tier 1 & 2 Gen: 58%; Tier 3 & 4 Brand: 45%

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