2020 Plan HighlightsExperience 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 Services20% of cost
X-rays (Outpatient)$35 copay
Diagnostic Radiology (MRI, CT Scan)20% of cost
Durable Medical Equipment20% of cost
Diabetes Supplies$0 copay
Medicare Part B Drugs (including chemotherapy)20% of cost
Additional Benefits
Fitness ProgramsSilverSneakers® 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 Benefits30-Day90-Day
Mail Order
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:* Specialty30% coinsurance30% coinsurance
Tier 6: Select Care Drugs$0 copay$0 copay

*Subject to $150 drug deductible