This new plan is everything you want in a Medicare plan and more, including a low monthly premium, a long list of valuable extras and low Maximum Out-of-Pocket costs to help protect your savings.
|Plan Highlights||Experience Health Medicare Advantage (HMO)|
|Monthly Plan Premium||$20|
|Maximum Out-of-Pocket Amount||$4,980 (in-network) per calendar year|
|Doctor and Hospital Visits|
|Primary Care Doctor Copay||$0 per visit|
|Specialist Copay||$35 per visit|
|Physical Therapy||$35 copay|
|Mental Health Service||$35 Outpatient individual/group therapy visit|
|Urgent Care Copay||$50 copay|
|Emergency Room Visit||$90 copay|
|Outpatient Hospital||$300 copay|
|Inpatient Hospital||$300 per day for days 1 – 6; $0 for days 7 and beyond|
|Skilled Nursing Facility||$0 per day for days 1 – 20; $165 per day for days 21 – 60; $0 per day for days 61 – 100|
|Ambulance Services||$375 copay|
|Diagnostics and Supplies|
|Lab Services||20% of cost|
|X-rays (Outpatient)||$35 copay|
|Diagnostic Radiology (MRI, CT Scan)||20% of cost|
|Durable Medical Equipment||20% of cost|
|Diabetes Supplies||$0 copay|
|Medicare Part B Drugs (including chemotherapy)||20% of cost|
|Fitness Programs||SilverSneakers® included at no additional cost|
|Preventive Dental Allowance||$200 per calendar year|
|Routine Eye Exam||$20 copay|
|Eyewear Allowance (contacts, eyeglasses, eyeglass frames, eyeglass lenses)||$200 per calendar year|
|Hearing Exam/Hearing Aids||$0 copay for routine exam; $699 - $999 copay per hearing aid|
|Prescription Drug Benefits||30-Day||90-Day
|Tier 1: Preferred Generic||$0 copay||$0 copay|
|Tier 2: Generic||$5 copay||$12.50 copay|
|Tier 3:* Preferred Brand||$45 copay||$112.50 copay|
|Tier 4:* Non-preferred Drug||$99 copay||$247.50 copay|
|Tier 5:* Specialty||30% coinsurance||30% coinsurance|
|Tier 6: Select Care Drugs||$0 copay||$0 copay|
*Subject to $150 drug deductible
Stay fit and feel good with access to over 11,000 gyms and fitness centers.
Dental health is better for overall health, so we’ve included a $200 per calendar year allowance.
Save money on vision care with a low $20 copay.
Includes contacts, eyeglasses, eyeglass frames, eyeglass lenses — it’s easy to see how this $200 per calendar year allowance is good to have.
You’ll like the sound of this: $0 copay for routine exam; $699-$999 copay per hearing aid.
Leaving town? Pack your Experience Health card for peace of mind.
You’ll have the help of a dedicated Care Support team member to help you manage health conditions and meet your health care goals.