HAP Member Assist
PPO

Price: $6.30, per month

Plan Specifics

Star Rating
Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$6.30
Contract ID
H2322-017
Annual Medical Deductible
$0
Annual Prescription Deductible
$500 T3-T5 (depending on level of LIS)
Max Enrollee Out-of-Pocket
$5,600 Annual In-Network
$5,600 Combined In and Out-of-Network
Plan Details

Plan Covered Medical Benefits

Category In-Network Out-of-Network
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.
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®.
Ambulance $300 copay. $300 copay.
Ambulatory Surgical Center $225 copay. 20% coinsurance.
Annual Physical Medicare-covered Benefits: Covered. The Routine Physical Exam is covered once per calendar year. 20% coinsurance.
Chiropractic Services 1 Office visit per year: $15 copay 1 set of X-rays per year: $35 copay Manual Manipulation of Spine: $15 copay. 20% coinsurance.
Dental Services Preventive & comprehensive dental through Delta Dental PPO Network- Includes $1,500 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, 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 $1,500 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, 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.
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. 20% coinsurance. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.
Diagnostic Procedures (Includes Genetic Testing) /Lab Services/Imaging Diagnostic Procedures/Tests: $0 - $65 copay. X-Ray Services: $35 copay. Therapeutic Radiological Services: 20% coinsurance. Diagnostic Procedures/Tests: 20% coinsurance. X-Ray Services: 20% coinsurance. Therapeutic Radiological Services: 20% coinsurance.
High-Tech Diagnostic Radiology Services $0 peripheral vascular disease ultrasounds. $200 high tech diagnostic tests. (CT, MRI, PET scan). 20% coinsurance for peripheral vascular disease ultrasounds. 20% coinsurance for high tech diagnostic tests. (CT, MRI, PET scan).
Doctor's Office Visits Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $30 copay. $0 copay applies for diabetic condition specific podiatry services. 20% coinsurance.
Emergency Care Emergency Room: $130 copay. Emergency Room: $130 copay.
Flexcard $65 per qtr for OTC and copays for plan covered services such as: physician services, lab work, PT/OT/ST. (excludes supplemental benefits provided by a vendor & prescription drugs); includes retail, with no rollover
.		 $65 per qtr; after 50% coinsinsurance for OTC and copays for plan covered services such as: physician services, lab work, PT/OT/ST. (excludes supplemental benefits provided by a vendor & prescription drugs); includes retail, with no rollover
.
Foot Care (Podiatry Services) Podiatry Services and Routine Foot Care: $0 - $30 copay. Podiatry Services: 20% coinsurance. Routine Foot Care: 20% coinsurance.
Hearing Services Medicare-covered Benefits: $0 - $30 copay. Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®. Medicare-covered Benefits: 20% coinsurance.
Inpatient Hospital Care $335 per day for days 1 through 7. $0 per day for days 8 through 90. 20% coinsurance.
Meal Benefit Limited to 2 discharges per year of 28 meals /14 days; max of 56 meals per year. Limited to 2 discharges per year of 28 meals /14 days; max of 56 meals per year.
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: 20% coinsurance. Prosthetic Devices: 20% coinsurance. Diabetic Supplies and Services: 20% coinsurance.
Mental Health Services $15 copay. 20% coinsurance.
Optional Dental Benefit Member pays: Additional $48.50 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 & Premier Network.		 Member pays: Additional $48.50 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 & Premier Network.
OTC Coverage available with Flex Card allowance. (See Flex Card details above). Coverage available with Flex Card allowance. (See Flex Card details above).
Other Diagnostic Test/Procedures Pacemaker testing, bone density testing, surgical supplies (splints and casts included): $0 copay. Pacemaker testing, bone density testing, surgical supplies (splints and casts included): 20% coinsurance.
Outpatient Hospital & Observation Services Outpatient hospital $275 copay.
Non-surgical services $100 copay.		 20% coinsurance.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $30 copay. 20% coinsurance.
Outpatient X-rays $35 copay. 20% coinsurance.
Preventive Care Covered at 100%. 20% coinsurance.
Fitness Benefits As a member, you have a fitness benefit through One Pass ® at no additional cost. Access to one of the largest fitness networks in the nation. As a member, you have a fitness benefit through One Pass ® at no additional cost. Access to one of the largest fitness networks in the nation.
Skilled Nursing Facility $10 copay for days 1 to 20. $221 copay for days 21 to 100. 20% coinsurance for days 1 to 20. 20% coinsurance for days 21 to 100.
Therapeutic radiology services, such as radiation treatment for cancer 20% coinsurance. 20% coinsurance.
Ultrasounds $65 copay. 20% coinsurance.
Urgently Needed Services Urgent Care: $50 copay. Urgent Care: $50 copay.
Vision Services Medicare-covered Benefits: $0 - $30 copay. Routine Eye Exam: $0 through Eyemed Insight Network. Medicare-covered Benefits: 20% coinsurance.
Wellness Programs Fitness Benefit, Nutritional/Dietary Counseling, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs. Fitness Benefit, Nutritional/Dietary Counseling, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs.

Prescription Drug Benefits

Coverage Type: Part D
Disclaimer
If you’re in a program that helps pay for your drugs (Extra Help), the information about costs for Part D drugs may not apply to you.
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 $13 $39 $39 $7 $21 $0
Tier 3 - Preferred Brand 22% 22% 22% 20% 20% 20%
Tier 4 - Non-Preferred Brand 27% 27% 27% 25% 25% 25%
Tier 5 - Specialty Tier 28% N/A N/A 28% 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.

Plan Documents

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