SeniorCare (Cost) HMO Plan H4564 Premiums - 2012
Premiums**
Medical Plans
Select($40.00 per month) |
Preferred($87.00 per month) |
VIP($125.00 per month) |
MedOption($148.00 per month) |
Premium($167.00 per month) |
Medical Plans with optional Prescription Plans added (Additional monthly premium required for prescription plans.)
| With Value Rx ($30.60) | With Basic Rx ($37.00) | With Enhanced Rx ($93.10) | |
| Select | $70.60 | $77.00 | $133.10 |
| Preferred | $117.60 | $124.00 | $180.10 |
| VIP | $155.60 | $162.00 | $218.10 |
| MedOption | $178.60 | $185.00 | $241.10 |
| Premium | $197.60 | $204.00 | $260.10 |
See the SeniorCare (Cost) HMO Plan Summary of Benefits 
for complete details on the medical and prescription plans. The SeniorCare (Cost) HMO Plan prescription plans are only available to SeniorCare (Cost) HMO Plan members.
**Rates are per member with Medicare A & B. All Medicare beneficiaries may apply. For all plans, members must continue to pay Medicare Part B premiums if not otherwise paid for under Medicaid or by another third-party.
The benefit information provided is not comprehensive. Additional information should be requested before making a decision about your coverage.
You must receive all routine care from plan providers.
Rates are illustrative only.
Premium not based on age, gender, or geographic location.
Do not send money until after you have been accepted for coverage.
You must fill out an application to apply for SeniorCare (Cost) HMO Plan coverage.
See Summary of Benefits for all benefit exclusions and limitations.
You may disenroll by mailing or faxing a signed written notice to a Scott & White Health Plan office or by calling 1-800 Medicare.
The above information is current as of October 2011.
Medicare-Approved HMO plan
H4564_WEB_SC_PREM_2012REV CMS Approved 11/09/2011