HAP MSU-HC Medicare Prime
PPO

Price: $0.00, per month

Plan Specifics

Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$0
Contract ID
H2322-016
Annual Medical Deductible
$0
Annual Prescription Deductible
$200
Max Enrollee Out-of-Pocket
$5,300 Annual In-Network
$5,300 Combined In and Out-of-Network
Plan Details

Medicare-Covered Medical Benefits

Category In-Network Out-of-Network
Preventive Care Covered at 100%. 35% coinsurance.
Doctor's Office Visits Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $35 copay; $0 copay applies for diabetic condition specific podiatry services. Primary Care Provider Office Visit: $20 copay. Specialist Office Visit: $45 copay.
Annual Physical Medicare-covered Benefits: Covered. The Routine Physical Exam is covered once per calendar year. 35% coinsurance.
Inpatient Hospital Care $350 per day for days 1 through 5. $0 per day for days 6 through 90. 35% coinsurance.
Emergency Care Emergency Room: $125 copay. Emergency Room: $125 copay.
Urgently Needed Services Urgent Care: $45 copay. Urgent Care: $45 copay.
Ambulance $300 copay. $300 copay.
Ambulatory Surgical Center $275 copay. 35% coinsurance.
Chiropractic Services 1 Office visit per year: $20 copay 1 set of X-rays per year: $35 copay Manual Manipulation of Spine: $20 copay. 35% coinsurance.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $20 copay. 35% coinsurance.
Outpatient Hospital & Observation Services $325 copay. 35% coinsurance.
Medical Equipment/Supplies Durable Medical Equipment: 20% coinsurance. Prosthetic Devices: 20% coinsurance. Diabetic Supplies and Services: $0 - 20% coinsurance. 20% coinsurance for continuous glucose monitors when obtained at a DME provider. $0 copay for continuous glucose monitors when obtained at a pharmacy. $0 copay for all other diabetic supplies and services. Durable Medical Equipment: 35% coinsurance. Prosthetic Devices: 35% coinsurance. Diabetic Supplies and Services: 35% coinsurance.
Diagnostic Procedures/Lab Services/Imaging Diagnostic Procedures/Tests: $0 - $200 copay. X-Ray Services: $35 copay. Therapeutic Radiological Services: $35 copay. Diagnostic Procedures/Tests: 35% coinsurance. X-Ray Services: 35% coinsurance. Therapeutic Radiological Services: 35% coinsurance.
High-Tech Diagnostic Radiology Services $0 peripheral vascular disease ultrasounds. $250 high tech diagnostic tests. (CT, MRI, PET scan). 35% coinsurance for peripheral vascular disease ultrasounds. 35% coinsurance for high tech diagnostic tests. (CT, MRI, PET scan).
Diagnostic Tests, Procedure & Lab Services (including genetic testing) $200 copay. 35% coinsurance.
Other Diagnostic Test/Procedures Pacemaker testing, allergy testing, bone density testing, surgical supplies (splints and casts included): $0 copay. Pacemaker testing, allergy testing, bone density testing, surgical supplies (splints and casts included). 35% coinsurance for pacemaker testing & allergy testing.
Ultrasounds $35 copay. 35% coinsurance.
Outpatient X-rays $35 copay. 35% coinsurance.
Therapeutic radiology services, such as radiation treatment for cancer $35 copay. 35% coinsurance.
Mental Health Services $15 copay. 35% coinsurance.
Foot Care (Podiatry Services) Podiatry Services and Routine Foot Care: $0 - $35 copay; $0 copay applies for diabetic condition specific podiatry services. Podiatry Services: 35% coinsurance. Routine Foot Care: 35% coinsurance.
Skilled Nursing Facility $0 copay for days 1 to 20. $214 copay for days 21 to 100. 35% coinsurance for days 1 to 20. 35% coinsurance for days 21 to 100.
Additional Services
Not Covered By Medicare
   None
Hearing Services Medicare-covered Benefits: $0 - $35 copay. Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®. Medicare-covered Benefits: $20-$45 copay.
Allowance for Hearing Aids Hearing Aids (All Types): Covered. All Types: $0 - $1575 copay. Must use NationsHearing®. Hearing Aids (All Types): Covered. All Types: $0 - $1575 copay. Must use NationsHearing®.
Vision Services Medicare-covered Benefits: $0 - $35 copay. Routine Eye Exam: $0 through Eyemed Insight Network. Medicare-covered Benefits: 35% coinsurance.
Allowance for Eyewear Contact Lenses: Covered. Eyeglasses (Lenses and Frames): Covered. $150 allowance. Must use Eyemed insight network. Contact Lenses: Covered. Eyeglasses (Lenses and Frames): Covered. $150 allowance. Must use Eyemed insight network.
Dental Services Preventive & comprehensive dental through Delta Dental PPO Network- Includes $2,000 max for preventive and comprehensive services combined; including 2 oral exams, 2 cleanings or 2 periodontal cleanings, 2 fluoride treatments, brush biopsy, 1 set of bitewings per year and 50% on root canals, fillings, onlays, crowns, crown repairs and simple extractions. Doesn't apply to Ded or MOOP. No prior auth or referral required. For the buy-up dental option review at bottom. Preventive & comprehensive dental through Delta Dental PPO Network- Includes $2,000 max for preventive and comprehensive services combined; including 2 oral exams, 2 cleanings or 2 periodontal cleanings, 2 fluoride treatments, brush biopsy, 1 set of bitewings per year and 50% on root canals, fillings, onlays, crowns, crown repairs and simple extractions. Doesn't apply to Ded or MOOP. No prior auth or referral required. For the buy-up dental option review at bottom.
Wellness Programs Fitness Benefit, Memory Fitness provided by BrainHQ®, Nutritional/Dietary, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Fitness Benefit, Memory Fitness provided by BrainHQ®, Nutritional/Dietary, Unlimited Sessions of Smoking & Tobacco Cessation Counseling.
Transportation Coverage available with Flex Card allowance. (See Flex Card details below). Coverage available with Flex Card allowance. (See Flex Card details below).
Flexcard $105 per qtr with rollover to next qtr for dental, vision, hearing, OTC, transportation, & healthy food/produce; includes retail. $105 per qtr with rollover to next qtr for dental, vision, hearing, OTC, transportation, & healthy food/produce; includes retail.
SilverSneakers® fitness benefits As a member, you have a fitness benefit through SilverSneakers® at no additional cost. SilverSneakers® can help you live a healthier, more active life through fitness and social connection. You are covered for a fitness benefit through SilverSneakers® at participating locations. You have access to instructors who lead specially designed group exercise classes. At participating locations nationwide, you can take classes plus use exercise equipment and other amenities. Additionally, SilverSneakers FLEX® gives you options to get active outside of traditional gyms (like recreation centers, malls and parks). SilverSneakers also connects you to a support network and virtual resources through SilverSneakers LIVE™ classes, SilverSneakers On-Demand™ videos and our mobile app, SilverSneakers GO™. As a member, you have a fitness benefit through SilverSneakers® at no additional cost. SilverSneakers® can help you live a healthier, more active life through fitness and social connection. You are covered for a fitness benefit through SilverSneakers® at participating locations. You have access to instructors who lead specially designed group exercise classes. At participating locations nationwide, you can take classes plus use exercise equipment and other amenities. Additionally, SilverSneakers FLEX® gives you options to get active outside of traditional gyms (like recreation centers, malls and parks). SilverSneakers also connects you to a support network and virtual resources through SilverSneakers LIVE™ classes, SilverSneakers On-Demand™ videos and our mobile app, SilverSneakers GO™.
OTC Coverage available with Flex Card allowance. (See Flex Card details above). Coverage available with Flex Card allowance. (See Flex Card details above).
Digital Diabetes Program For members already enrolled in HAP's Digital Diabetes program who also have a diagnosis of hypertension additional tools are available to help dual-diagnosed members manage both of these conditions including assistance with weight management and their emotional wellbeing. For members already enrolled in HAP's Digital Diabetes program who also have a diagnosis of hypertension additional tools are available to help dual-diagnosed members manage both of these conditions including assistance with weight management and their emotional wellbeing.
Diabetes Management Robust care for diabetics at affordable cost. $0 cost share for critical diabetes prevention and care on items such as podiatry visits and virtual care check ups. $0 podiatry visits for diabetics. $0 Continuous Glucose monitor when filled at a pharmacy. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible. Robust care for diabetics at affordable cost. $0 cost share for critical diabetes prevention and care on items such as podiatry visits and virtual care check ups. $0 podiatry visits for diabetics. $0 Continuous Glucose monitor when filled at a pharmacy. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.
Optional Dental Benefit - Delta 50 Member pays: Additional $19.90 per month. Benefits Include: $0 Deductible Max Benefit $2,000. Plan Pays: Comprehensive Svcs 0% - 100%; Does not apply to Ded or MOOP; No prior auth or referral required. Delta Dental PPO Network. Member pays: Additional $19.90 per month. Benefits Include: $0 Deductible Max Benefit $2,000. Plan Pays: Comprehensive Svcs 0% - 100%; Does not apply to Ded or MOOP; No prior auth or referral required. Delta Dental PPO Network.

Prescription Drug Benefits

Coverage Type: Part D
Pre-initial coverage limit
Standard Retail Cost Sharing - One Month Supply
Standard Retail Cost Sharing - Three Month Supply
Standard Mail Order Cost Sharing - Three Month Supply
Preferred Retail Cost Sharing - One Month Supply
Preferred Retail Cost Sharing - Three Month Supply
Preferred Mail Order Cost Sharing - Three Month Supply
Tier 1 - Preferred Generic $9 $27 $27 $0 $0 $0
Tier 2 - Generic $17 $51 $51 $11 $33 $0
Tier 3 - Preferred Brand 20% 20% 20% 18% 18% 18%
Tier 4 - Non-Preferred Brand 50% 50% 50% 48% 48% 48%
Tier 5 - Specialty Tier 30% N/A N/A 30% N/A N/A

Important Message About What You Pay for Insulin - You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on.

Per CMS, insulin administered with an insulin pump, other than Omnipod Dash, is covered as a Medicare Part B (medical) benefit. Members are responsible for Part B cost-share. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.

Plan Documents

2025 Medicare Star Ratings
Summary Of Benefits
Delta Dental (Find A Dentist)
Find a HAP Doctor
HAP Medicare Member Resources
HAP Medicare Options
Nations Hearing
Over-the-Counter Benefit