HAP Medicare Connect
HMO
Price: $0.00, per month
Price: $0.00, per month
Plan Specifics
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Star Rating
The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use the Star Rating to compare our plan’s performance to other plans. Examples of the areas covered by this rating include:
- How our members rate our plan’s services and care
- How well our doctors detect illnesses and keep members healthy
- How well our plan helps out members use recommended and safe prescription medications
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- Coverage Type
- Part A, Part B, Part D
- Monthly Plan Premium
- $0
- Contract ID
- H2354-015
- Annual Medical Deductible
- $0
- Annual Prescription Deductible
- $200
- Max Enrollee Out-of-Pocket
- $5,600 Annual In-Network
Plan Covered Medical Benefits
| Category | In-Network |
|---|---|
| Allowance for Eyewear | 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®. |
| Ambulance | $300 copay. |
| Ambulatory Surgical Center | $325 copay. |
| Annual Physical | Medicare-covered Benefits: Covered. The Routine Physical Exam is covered once per calendar year. |
| Chiropractic Services | 1 Office visit per year: $15 copay 1 set of X-rays per year: $35 copay Manual Manipulation of Spine: $15 copay. |
| 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. 25% on onlays, crowns, crown repairs. 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. |
| Diagnostic Procedures (Includes Genetic Testing) /Lab Services/Imaging | Diagnostic Procedures/Tests: $0 - $150 copay X-Ray Services: $35 copay Therapeutic Radiological Services: 20% coinsurance. |
| High-Tech Diagnostic Radiology Services | $0 peripheral vascular disease ultrasounds. $300 high tech diagnostic tests. (CT, MRI, PET scan). |
| Doctor's Office Visits | Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $45 copay; $0 copay applies for diabetic condition specific podiatry services. |
| Emergency Care | Emergency Room: $130 copay. |
| Foot Care (Podiatry Services) | Podiatry Services and Routine Foot Care: $0 - $45 copay; $0 copay applies for diabetic condition specific podiatry services. |
| Hearing Services | Medicare-covered Benefits: $0 - $45 copay. Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®. |
| Inpatient Hospital Care | $375 per day for days 1 through 6. $0 per day for days 7 through 90. |
| 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 applies for all other diabetic supplies and services. |
| Mental Health Services | $15 copay. |
| Optional Dental Benefit | Member pays: Additional $38.90 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 & Premier Network. |
| Other Diagnostic Test/Procedures | Pacemaker testing, bone density testing, surgical supplies (splints and casts included): $0 copay. |
| Outpatient Hospital & Observation Services | Outpatient hospital $375 copay. Non-surgical services $145 copay. |
| Outpatient Therapy (Physical, Occupational, Speech, Cardiac) | $40 copay. |
| Outpatient X-rays | $35 copay. |
| Preventive Care | Covered at 100%. |
| 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. |
| Skilled Nursing Facility | $0 copay for days 1 to 20. $221 copay for days 21 to 100. |
| Therapeutic radiology services, such as radiation treatment for cancer | $25 copay. |
| Ultrasounds | $150 copay. |
| Urgently Needed Services | Urgent Care: $50 copay. |
| Vision Services | Medicare-covered Benefits: $0 - $45 copay. Routine Eye Exam: $0 through Eyemed Insight Network. |
| Wellness 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 | |||||
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Pre-initial coverage limit
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Standard Retail Cost Sharing - One Month Supply
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Standard Retail Cost Sharing - Three Month Supply
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Standard Mail Order Cost Sharing - Three Month Supply
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Preferred Retail Cost Sharing - One Month Supply
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Preferred Retail Cost Sharing - Three Month Supply
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Preferred Mail Order Cost Sharing - Three Month Supply
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|---|---|---|---|---|---|---|
| Tier 1 - Preferred Generic | $7 | $21 | $21 | $0 | $0 | $0 |
| Tier 2 - Generic | $14 | $42 | $42 | $8 | $24 | $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 | 31% | N/A | N/A | 31% | N/A | N/A |