Monthly premium
(The amount you pay each month.)
You must continue to pay your Medicare Part B premium. Low Income Subsidy can help pay for prescription drugs and monthly premiums. Find out more. | $0 | $120 |
In-network out-of-pocket maximum
(The most you pay each year for Medicare-covered services from in-network providers.) | $6,700 | $3,850 |
| 2024 Star Rating |  4 out of 5 Star Rating (H3832 [PDF]). |
| Provider directory | |
| Medical Benefits* |
| | You Pay | You Pay |
| Annual deductible | $0 | $0 |
| Inpatient hospital care* | Days 1 to 6:
$370/day Days 7 to 60:
$50/day Days 61 to 90:
$0/day | Days 1 to 5:
$350/day Days 6 to 90:
$0/day Additional Days:
$0/day |
| Skilled nursing facility* | Days 1 to 20:
$0/day Days 21 to 60:
$200/day Days 61 to 100:
$0/day | Days 1 to 20:
$20/day Days 21 to 40:
$190/day Days 41 to 100:
$0/day |
| Outpatient hospital facility and ambulatory surgical center services* | 20% | 20% |
| Primary care provider office visit | $0 | $0 |
| Specialty care provider office visit | $50 | $30 |
| Annual wellness visit | $0 | $0 |
Ambulance service
Includes ground and air. | $250 | $225 |
| Emergency care | $100 | $100 |
| Urgent care | $50 | $30 |
| Worldwide coverage for emergency and urgent care services | 10% | 10% |
| Diagnostic tests and procedures, lab services, and outpatient X-rays* | 20% | 20% |
| Medicare Part B drugs* | 20% | 20% |
| Medicare Part B insulin drugs* | $35 | $35 |
| Medical equipment and supplies* | 20% | 20% |
| Supplemental Dental Benefits |
| Preventive dental services, including two oral exams every year, two cleanings every year, one set of X-rays every year, and two fluoride treatments every year | $0 | $0 |
| Comprehensive dental services, including four extractions every year and two fillings every year | $0 | $0 |
| Comprehensive dental services, including one root canal every year and one crown following a root canal on the same tooth every year | Not covered | $0 |
| Dental Provider Directory | Dental Provider Directory [PDF] |
| Supplemental Vision Benefits |
| | You Pay | You Pay |
| Routine eye exam | $10/1 exam per calendar year | $0/1 exam per calendar year |
| Contact lenses and eyeglasses (frames and lenses) | $0
Plan pays up to $300 every calendar year | $0
Plan pays up to $300 every calendar year |
| Other Supplemental Benefits |
Over-the-Counter (OTC) Health Products OTC health and wellness products available at select retail stores or through mail order delivery online at HMSAExtra Benefits.com or by calling 1-800-790-6019. For more information, visit thedublinproject.com/ ExtraBenefits | $0 Plan pays $65 per quarter | $0 Plan pays $95 per quarter |
Over-the-Counter (OTC) Health Products Catalog | Over-the-Counter (OTC) Health Products Catalog [PDF] |
Fitness - Silver&Fit Healthy Aging and Exercise Program
A membership to a participating fitness center, one home fitness kit per year, Healthy Aging Coaching sessions and more. | Fitness Center Membership
$0/month for standard fitness center,
$30- $200/month for premium fitness center Home Fitness Kit
$0
1 Home Fitness Kit per calendar year Healthy Aging Coaching
$0 Digital Workout Videos
$0 | Fitness Center Membership
$0/month for standard fitness center,
$30- $200/month for premium fitness center Home Fitness Kit
$0
1 Home Fitness Kit per calendar year Healthy Aging Coaching
$0 Digital Workout Videos
$0 |
Telehealth services
Includes HMSA’s Online Care. | $0 | $0 |
| Health education | $0
Learn more | $0
Learn more |
| Health coaching | $0
Learn more | $0
Learn more |
| Drug Benefits |
| | You Pay | You Pay |
Annual deductible Low Income Subsidy can help pay for prescription drugs and monthly premiums. Find out more. | $380
Does not apply to tier 1 drugs, insulin and most Part D vaccines | $0
|
Initial coverage stage
Until total drug costs reach $5,030 |
| 30-day supply from retail pharmacies |
Tier 1 - Preferred Generic | $4.50 | $4 |
Tier 2 - Generic | $12 | $11 |
Tier 3 - Preferred Brand | $47 | $45 |
Tier 3 - Preferred Brand Inslulin | $35 | $35 |
Tier 4 - Non-Preferred Drug | $100 | $95 |
Tier 5 - Specialty | 27% | 33% |
Tier 5 - Specialty Insulin | $35 | $35 |
| 100-day supply from mail-order pharmacy |
Tier 1 - Preferred Generic | $4.50 | $4 |
Tier 2 - Generic | $12 | $11 |
Tier 3 - Preferred Brand | $94 | $90 |
Tier 3 - Preferred Brand Insulin | $70 | $70 |
Tier 4 - Non-Preferred Drug | $200 | $190 |
Tier 5 - Specialty | 27% | 33% |
Tier 5 - Specialty Insulin | $105 | $105 |
Coverage gap stage
Until your yearly out-of-pocket drug costs reach $8,000 | 25% of the cost of brand or generic drugs |
| Additional gap coverage for Tier 1 drugs |
| 30-day supply from retail pharmacy | Not covered | $4 |
| 100-day supply from mail-order pharmacy | Not covered | $4 |
Catastrophic coverage stage
After your yearly out-of-pocket drug costs
reach $8,000 | $0 for generic drugs (including brand drugs treated as generic) and all other drugs |
| Part D vaccines | $0 for most Part D vaccines on all drug tiers. |
| Pharmacy | Find a pharmacy |
Prescription Drugs List (Formulary)
See if your prescription drugs are covered and search for lower-cost alternatives. Drug Search Tool. | |
| Resources and Plan Materials |
| Summary of Benefits | Summary of Benefits [PDF] | Summary of Benefits [PDF] |
| Annual Notice of Changes | Annual Notice of Changes [PDF] | Annual Notice of Changes [PDF] |
| Evidence of Coverage | | |
| Member Resources | Learn more | Learn more |
