HAP Senior Plus Henry Ford Tiered Access
HMO
Price: $95.00, per month
Price: $95.00, per month
Plan Specifics
- Coverage Type
- Part A, Part B, Part D
- Monthly Plan Premium
- $95
- Contract ID
- H2354-018
- Annual Medical Deductible
- $0
- Annual Prescription Deductible
- $0
- Max Enrollee Out-of-Pocket
- $4,750 Annual In-Network
Medicare-Covered Medical Benefits
Category | In-Network |
---|---|
Preventive Care | Covered at 100%. |
Doctor's Office Visits | Tier 1: Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $30 copay; $0 copay applies for diabetic condition specific podiatry services. Tier 2: Primary Care Provider Office Visit: $35 copay. Specialist Office Visit: $50 copay; $0 copay applies for diabetic condition specific podiatry services. |
Annual Physical | Medicare-covered Benefits: Covered. The Routine Physical Exam is covered once per calendar year. |
Inpatient Hospital Care | Inpatient Hospital Coverage $275 per day for days 1 through 5. $0 per day for days 6 through 90 for tier 1 providers. Inpatient Hospital Coverage $350 per day for days 1 through 5. $0 per day for days 6 through 90 for tier 2 providers. |
Emergency Care | Emergency Room: $125 copay. |
Urgently Needed Services | Urgent Care: $45 copay. |
Ambulance | $275 copay. |
Ambulatory Surgical Center | $80 copay tier 1. $120 copay tier 2. |
Chiropractic Services | 1 Office visit per year: $20 copay 1 set of X-rays per year: $0 copay tier 1, $35 copay tier 2. Manual Manipulation of Spine: $20 copay. |
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) | $10 - $30 copay. |
Outpatient Hospital & Observation Services | $115 for tier 1 providers/facilities and $205 for tier 2 providers/facilities. |
Medical Equipment/Supplies | Durable Medical Equipment: 10% - 20% coinsurance. Tier 1 vendor 10%. Tier 2 vendor 20%. Prosthetic Devices: 10% - 20% coinsurance. Tier 1 vendor 10%. Tier 2 vendor 20%. Diabetic Supplies and Services: $0 - 20% coinsurance. Tier 1 vendor 0% coinsurance. Tier 2 vendor 20% coinsurance. 0% coinsurance applies for continuous glucose monitors when obtained at a pharmacy. 20% coinsurance applies for all other diabetic supplies and services. |
Diagnostic Procedures/Lab Services/Imaging | Diagnostic Procedures/Tests: $0-$100 copay for tier 1 providers/facilities and $0- $200 copay for tier 2 providers/facilities. X-Ray Services: $0 copay for tier 1 providers/facilities and $35 copay for tier 2 providers/facilities. Therapeutic Radiological Services: $25 copay for tier 1 providers/facilities and $40 copay for tier 2 providers/facilities. |
High-Tech Diagnostic Radiology Services | Tier 1: $0 peripheral vascular disease ultrasounds. $100 high tech diagnostic tests.(CT, MRI, PET scan).Tier 2: $0 peripheral vascular disease ultrasounds.$200 high tech diagnostic tests.(CT, MRI, PET scan). |
Diagnostic Tests, Procedure & Lab Services (including genetic testing) | Tier 1: $100 copay. Tier 2: $200 copay. |
Other Diagnostic Test/Procedures | Pacemaker testing, allergy testing, bone density testing, surgical supplies (splints and casts included). Tier 1: $0 copay. Tier 2: $0 copay. |
Ultrasounds | Tier 1: $0 copay. Tier 2: $35 copay. |
Outpatient X-rays | Tier 1: $0 copay. Tier 2: $35 copay. |
Therapeutic radiology services, such as radiation treatment for cancer | Tier 1: $25 copay. Tier 2: $40 copay. |
Mental Health Services | Tier 1: $0 copay. Tier 2: $35 copay. |
Foot Care (Podiatry Services) | Podiatry Services and Routine Foot Care: $0 - $50 copay; $0- $30 for tier 1 and $0-50 tier 2. $0 copay applies for diabetic condition specific podiatry services. |
Skilled Nursing Facility | $0 copay for days 1 to 20. $214 copay for days 21 to 100. |
Not Covered By Medicare |
  |
Hearing Services | Medicare-covered Benefits: $0 - $50 copay. Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®. |
Allowance for Hearing Aids | Hearing Aids (All Types): Covered. All Types: $0 - $1575 copay. Must use NationsHearing®. |
Vision Services | Medicare-covered Benefits: $0 - $50 copay. Routine Eye Exam: $0 through Eyemed Insight Network. |
Allowance for Eyewear | 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. |
Wellness Programs | Fitness Benefit, Memory Fitness provided by BrainHQ®, Nutritional/Dietary, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. |
Transportation | 12 one-way trips - Includes doctor, dentist, optical, hearing and pharmacy visits. Powered by Veyo®. |
Flexcard | $75 per qtr; with rollover to next qtr for OTC & 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™. |
OTC | 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. |
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. |
Meal Benefit | Limited to 2 discharges per year of 28 meals /14 days; max of 56 meals per year. |
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. |
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 | $7 | $21 | $21 | $0 | $0 | $0 |
Tier 2 - Generic | $16 | $48 | $48 | $9 | $27 | $0 |
Tier 3 - Preferred Brand | 22% | 22% | 22% | 20% | 20% | 20% |
Tier 4 - Non-Preferred Brand | 50% | 50% | 50% | 48% | 48% | 48% |
Tier 5 - Specialty Tier | 33% | N/A | N/A | 33% | N/A | N/A |