Henry Ford Select
HMO

Price: $0.00, per month

Plan Specifics

Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$0
Contract ID
H2354-029
Annual Medical Deductible
$0
Annual Prescription Deductible
$150
Plan Details

Medicare-Covered Medical Benefits

Category In-Network
Preventive Care Covered at 100%.
Doctor's Office Visits Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $15 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 $250 per day for days 1 through 6. $0 per day for days 7 through 90.
Emergency Care Emergency Room: $150 copay.
Urgently Needed Services Urgent Care: $15 copay.
Ambulance $300 copay.
Ambulatory Surgical Center $100 copay.
Chiropractic Services 1 Office visit per year: $15 copay 1 set of X-rays per year: $35 copay Manual Manipulation of Spine: $15 copay.
Diabetes Screening, Diabetes Self- Management Training, Diabetic Services & Supplies $0 copay. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $10 copay.
Diagnostic Procedures (Includes Genetic Testing) /Lab Services/Imaging Diagnostic Procedures/Tests: $0 - $150 copay. X-Ray Services: $35 copay. Therapeutic Radiological Services: $25 copay.
Outpatient Hospital & Observation Services Outpatient hospital $200 copay.
Non-surgical services $100 copay.
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.
High-Tech Diagnostic Radiology Services $0 peripheral vascular disease ultrasounds. $200 high tech diagnostic tests. (CT, MRI, PET scan).
Other Diagnostic Test/Procedures Pacemaker testing, allergy testing, bone density testing, surgical supplies (splints and casts included): $0 copay.
Ultrasounds $150 copay.
Outpatient X-rays $35 copay.
Therapeutic radiology services, such as radiation treatment for cancer $25 copay.
Mental Health Services $15 copay.
Foot Care (Podiatry Services) Podiatry Services and Routine Foot Care: $0 - $15 copay. $0 copay for Diabetic Podiatry Services.
Skilled Nursing Facility $0 copay for days 1 to 20. $218 copay for days 21 to 100.
Additional Services
Not Covered By Medicare
  
Hearing Services Medicare-covered Benefits: $0 - $15 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 - $15 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; 100% coverage for: 2 oral exams, 2 cleanings or 2 periodontal cleanings, 2 fluoride treatments, brush biopsy, 1 set of bitewings per year, root canals, fillings, bridges, bridge repairs, onlays, crowns, crown repairs, perio surgical/non surgical procedures, surigcal extractions/oral surgery, emergency palliative treatment, occlusal guards/adjustments, anesthesia and simple extractions. Doesn't apply to Ded or MOOP. No prior auth or referral required.
Wellness Programs Fitness Benefit, Nutritional/Dietary Counseling, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs.
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™.
Flexcard $145 per qtr; With rollover. Use towards OTC, healthy food/produce & plan covered services such as: physician services, lab work, PT/OT/ST. (excludes supplemental benefits provided by a vendor & prescription drugs); includes retail.

*This benefit is a special supplemental benefit for the chronically ill (SSBCI) and is made available to members with one or more qualifying chronic conditions. Not all members will qualify for this benefit. Qualifying chronic conditions include but are not limited to diabetes, cardiovascular disorders, chronic lung disorders, cancer, and dementia. For a complete list of qualifying chronic conditions please see the plan’s Evidence of Coverage (EOC).
OTC Coverage available with Flex Card allowance. (See Flex Card details above).

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 $15 $45 $45 $9 $27 $0
Tier 3 - Preferred Brand 17% 17% 17% 15% 15% 15%
Tier 4 - Non-Preferred Brand 39% 39% 39% 37% 37% 37%
Tier 5 - Specialty Tier 31% N/A N/A 31% 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 covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible.

Insulins administered with an infusion pump are covered as a Part B medical benefit. You won’t pay more than $35 for one-month supply of insulin, with no deductible.