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2017 Vital Traditions Advantage HMO Plan Information

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2017 Vital Traditions Pharmacy Services

Learn more about Vital Traditions (HMO) and Vital Traditions (HMO-POS) prescription services with these helpful resources.

 

Have your prescriptions filled at any of our pharmacy network locations.
2017 Pharmacy Directory


Download our list of covered drugs.
2017 Drug List (Formulary)


Fill out this form to request medications requiring prior authorization.
Online Prescription Drug Prior Authorization Form


Other helpful documents


Save money on a 90-day supply

You can save money by obtaining and receiving 90-day supplies of your maintenance medications for two copayments at participating pharmacies. The Pharmacy Directory indicates which pharmacies provide a 90-day supply (also called an extended day supply). Contact customer service to see if your pharmacy participates.

 

 

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Two plans that will rate well with your budget

Vital Traditions (HMO) gives your Original Medicare plan a real boost with a $0 monthly premium. If you need to see out-of-network providers, then consider Vital Traditions (HMO-POS) with a $20 monthly premium.


Full summary of benefits

Cost Comparison Vital Traditions (HMO)
You Pay
Vital Traditions (HMO-POS)
You Pay
Premiums $0 $20
Deductible No No
Inpatient Hospital Stay $250 copay per day for days 1 through 5.
You pay nothing per day for days 6 through 90.
In-network:

$250 copay per day for days 1 through 5. You pay nothing per day for days 6 through 90.

Out-of-network:
30% of the cost per stay
Doctor Office Visit $0 In-network: $0
Out-of-network: 30%
Specialist Office Visit $40 In-network: $40
Out-of-network: 30%
Prescription Drug Copay $2, $10, $45, $95, 31% $2, $10, $45, $95, 31%
 Hearing $40 copay on 1 hearing exam per year.

Hearing Aid covered up to $1,000 every 3 years. Supply of batteries and warranty included. You must use a Hear USA provider. 

In-network: Hearing Aid covered up to $1,000 every 3 years. Supply of batteries and warranty included. You must use a Hear USA provider. 

Out-of-network: Hearing aids, fittings and evaluation are not covered.
Vision $0 copay for routine eye exams

$125 eyewear allowance toward the total cost of hard contacts or frames or lenses or glasses 1 time per year. There is no copay for eyewear. Members must use a participating Superior Vision provider.
Routine eye exam:

In-network: $0 copay for routine eye exams

Out-of-network: Routine eye exams are Not covered. 

Eyeglasses (frames and lenses):

In-network: $125 eyewear allowance toward the total cost of hard contacts or frames or lenses or glasses 1 time per year. There is no copay for eyewear. Members must use a participating Superior Vision provider.

Out-of-network: Eyewear is not covered except following Medicare-covered services for glaucoma surgery.



Optional Dental Available for an extra premium of $17 per month Available for an extra premium of $17 per month

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.


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See to your prescription needs

A prescription drug plan comes standard with Vital Traditions (HMO) and Vital Traditions (HMO-POS). The HMO option is available with no monthly premium ($0). If you want even more choice, Vital Traditions (HMO-POS) has a low $20 monthly premium. Both plans offer:

  • Hundreds of 2017 in-network pharmacies across Texas
  • Convenient home delivery mail order service
  • 90-day supply of maintenance drugs, available for two copayments
  • Access to a complete range of generic and brand-name drugs
Plan Type Vital Traditions (HMO) and Vital Traditions (HMO-POS)
Initial Coverage Amount $3,700
Deductible $100
Copays During Initial Coverage Period
 Tier 1 — Preferred Generic Drugs $2
 Tier 2 — Non-Preferred Generic Drugs $10
 Tier 3 — Preferred Brand Drugs $45
 Tier 4 — Non-Preferred Brand Drugs $95
 Tier 5 — Specialty Drugs  31%
Coverage Gap
Generic Drugs 51%
Brand Drugs
40%
All Other Drugs
100% 
Total Out-of-Pocket you pay before Catastrophic Coverage $4,950
Catastrophic Coverage Amounts You Pay the Greater of:
Generic Drugs (including brand drugs treated as generic)
All Other Drugs
5% or
$3.30
$8.25

 


The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Members must use network pharmacies to access their prescription drug benefit except under non-routine circumstances, and quantity limitations and restrictions may apply. Our network of pharmacies has both local and chain pharmacies. You can fill prescriptions at either.