skip to main content

Text/HTML

Benefits Highlights

Text/HTML

 

 SeniorCare (Cost) VIP HMO


Summary

This plan is a Medicare HMO Cost plan. You may add Part D Prescription Drug Coverage for an additional monthly premium.

$130 Monthly Premium

(in addition to your
Medicare Part B premium)


in-network
cost sharing
Annual Medical Deductible $0
Out-of-Pocket Maximum $3,400


* This plan will be phased out at end of 2018, and will transfer into a new plan. Details of the 2019 plan transfer will be provided to plan members.

CEO Jeff Ingrum speaks about future changes to SeniorCare (Cost) plans: no immediate impact.  Watch Video

Doctors

 

 


in-network
you'll pay
Primary Care Physician (PCP) Office Visit $10 copay
Specialist Office Visit $10 copay
Diagnostic Tests, X-Ray, Lab Services
(separate office visit copay may apply)
$10 copay
Physical/Occupational/Speech Therapy $5 copay

 

Hospital Coverage



in-network
you'll pay
Emergency Care
(U.S. only; copay waived if admitted within 24 hours)
$125 copay
Urgent Care
(U.S. only; copay waived if admitted within 24 hours)
$40 copay
Ambulance (copay waived if admitted within 24 hours) $60 copay
Inpatient Hospital Facility $200 copay
per day for first five days (days 1-5),
then $0 for up to 90 days.
Skilled Nursing Facility (SNF) $0 copay
per day for first twenty days (days 1-20),
then $30 per day for up to 100 days.
Outpatient Surgery (Facility) $5 copay
Durable Medical Equipment (DME) 10% of cost

 

Prescription Drug Benefits

Find your prescription drug(s) for all SWHP Medicare plans in the Formulary Drug List.



(must use network pharmacies;
no out-of-network benefits)
Basic Rx Enhanced Rx
Additional Monthly Premium $76.50 $123.20
Deductible, applies to tiers 3-5 $100 $50
Initial Coverage Amount $3,750 $3,750
Copays During Initial Coverage Period
(30-day supply, not including 90-day supply savings)
Tiered
     Tier 1, Preferred Generic $4 $2
     Tier 2, Generic Drugs $20 $12
     Tier 3, Preferred Brand $47 $47
     Tier 4, Non-Preferred Brand $100 $95
     Tier 5, Specialty 31% 32%

 


 

Dental Plan Options

Dental insurance is now available during enrollment.

Learn more about the Dental Plan option.

Bonus Benefits

(all included with monthly premium)




Have any questions? Need language assistance?

Call Sales to talk to a licensed insurance agent at 1-800-782-5068 (TTY: 1-800-735-2989).

//